Patient Questionnaire - Switch Dental Lower Hutt

Title*

First Name(s)*

Last Name*

Address*

Suburb

Phone (Home)

Phone (Mobile)*

DOB*

Occupation

Work Address*

Suburb

Phone (Work)

Name*

Contact Number*

Medical Doctor

Contact Number

Past Dentist

Date of last visit

Do you have a history of any of the following conditions? (Tick all that apply)

Please specify 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?

Please write details here

Please tick all that apply

Other (please specify)

Name

This field is for validation purposes and should be left unchanged.