New Patient Questionnaire Learn about the patient experience at Switch Dental WHAT TO EXPECTNew Patient Form Fill in the form below to become a patient at Switch Dental. If you have any questions, please call us on 04 569 6808 Name(Required) Prefix Mr.Mrs.MissMs.Dr.Other. First Last Date of birth(Required) DD slash MM slash YYYY Email(Required) Address(Required) Street Address City Phone(Required)Work phoneOccupationEmployerEmployer address Street Address City Emergency contact personEmergency contact name(Required)Emergency contact number(Required)Medical HistoryYour Medical Practitioner (GP)(Required)Medical Practioner contact number(Required)Previous dental practiceDate of last dental visit DD slash MM slash YYYY Do you have a history of any of the following conditions? (tick all that apply): Arthritis Bleeding problems/Anaemia Chest problems/COPD/Asthma Cold sores Depression Diabetes Epilepsy/Fits/Fainting Gastric problems/kidney problems Heart problems Hepatitis A Hepatitis B Hepatitis C Hepatitis D High blood pressure Osteoporosis Rheumatic fever Drug/alcohol dependence Please select if yes to any of the following: Do you have any food, drug or other allergies? Have you been hospitalised in the past two years? Have you had any prosthetic surgery? (e.g. heart valve, stent, joint replacement, pacemaker etc.) Female only: Are you pregnant? Are you HIV positive? Have you taken any medicine, tablets, capsules or drugs in the past two years? If currently taking, please list Are you currently taking warfarin or fosamax? How did you hear about us?Is there anything else you'd like to share with us?CAPTCHA Ready to Get Started?Book your comprehensive new-patient exam today. It’s an honest, respectful way to get the clarity you deserve with zero pressure.BOOK ONLINE
