Form Test

Online Appointment

When you submit our online appointment request form below our staff will contact you to arrange a suitable time to visit us at Shepherds Hill Dental Centre.

If you are new to our practice you will need to complete our New Patient Information form so we can be sure to treat your individual needs. You can print the form, fill it in at your leisure and bring in with you to your first appointment. Alternatively, please arrive 10 minutes prior to your appointment time to fill it in here at the practice.

We look forward to seeing you at your visit to Shepherds Hill Dental Centre.

Online Appointment request

Online Appointment

Name*
First Name Last Name
Contact Number*
Mobile Number
Email*
If you are new to our practice how did you hear about us?
Would you like to?*
Please provide a brief description of the problem or treatment you require & we will contact you shortly*
Preferred time to be contacted*
Preferred Contact Method*
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

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Your Feedback

Your feedback, suggestion or compliment. Please be as specific as you can:*
If there are opportunities for us to do something better, sometimes a conversation can help us to find the best solution. Would you like us to contact you regarding your comments?
Please include your name and contact details for us to contact you. These fields are optional so if you wish your feedback to be anonymous then please leave them blank and click 'submit'.
Name
First Name Last Name
Contact Number
Email
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

Your Feedback

Your feedback, suggestion or compliment. Please be as specific as you can:*
If there are opportunities for us to do something better, sometimes a conversation can help us to find the best solution. Would you like us to contact you regarding your comments?
Please include your name and contact details for us to contact you. These fields are optional so if you wish your feedback to be anonymous then please leave them blank and click 'submit'.
Name
First Name Last Name
Contact Number
Email
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

New Patient Form

Step 1 of 3

PATIENT INFORMATION and HEALTH QUESTIONNAIRE

Please take the time to answer the following questions carefully as the information will help us to provide you with high quality dental care. All information given will be treated confidentially.
Name
First Name Last Name
I prefer to be called
Date of Birth

Day
Month
Year
Occupation
Name of person responsible for account (if not you):
Do you belong to a dental benefits fund?
If your answer in above's question is yes, please indicate the name of the fund
Please tell us who referred you to our practice:
Home Address
Address Line 1 Address Line 2 City State Postcode
Home Phone
Please include area code
Work Phone
Please include area code or specific mobile number if no landline
Mobile*
Email*
Work Address
Address Line 1 Address Line 2 City State Postcode
Emergency contact person:
First Name Last Name
Emergency contact phone number:

GENERAL HEALTH INFORMATION

The following information regarding your general health is important because your oral health can be affected by certain medical conditions. Some of the tablets or medications you take may also affect your treatment and may mean that we need to take special precautions for you. Please list all of your present medications (including over the counter treatments such as painkillers, vitamins and natural therapies) and any that you have taken in the last six months.
My General Medical Practitioner is
Telephone Number of General Medical Practitioner:
My Medical Specialist is
Telephone Number of Medical Specialist
I am currently having medical treatment
If you are currently having medical treatment, please specify for what condition?
For Females, are you pregnant or currently breastfeeding?
Have you ever had any of the following conditions?
I am taking the medications for the following conditions:
I have / have had in the past:
DENTAL HEALTH INFORMATION
My last dental check up was (how long ago)?
I expect to keep my own teeth for life
My gums bleed when I brush my teeth
Some of my teeth are sensitive to heat
I clench or grind my teeth
I have a clicking noise/pain in my jaw joints
I suffer from headaches
I am concerned about the colour/appearance of my teeth
I am concerned about the colour/appearance of my teeth
Is there anything else about your health that we should know?
Is there anything specific about going to the dentist that bothers you?
Is there anything you wish to discuss confidentially with the dentist?
THANK YOU FOR YOUR PATIENCE IN COMPLETING THIS QUESTIONNAIRE

Privacy Policy

Our commitment to privacy
Our practice is committed to safeguarding the personal information of patients and staff in line with our obligations under Commonwealth legislation as well as guidelines set by industry regulatory bodies such as the Australian Dental Board.
What information do we collect about patients and why?
Administrative data
Our practice collects administrative data for accounting purposes, including name, phone number, contact address/billing address, private health care fund and number, Medicare number (if required for government-sponsored programs), financial records of accounts and payments (kept for five years, as required by the Australian Taxation Office) insurance claims records, work related injuries (records kept for five years as required under WHS legislation), complaints.
Who else may see the information?
We may use patient information to discuss treatment with our practitioners. We may use it in a de-identified form for academic purposes, or with insurance officers or lawyers where the treatment relates to an Insurance claim or complaint.
Heath Identifiers
The practice will not adopt, use or disclose an identifier assigned by any government agency except health care identifiers for purposes permitted under the Healthcare Identifiers Act (2010) (Cwth).
Access and correction
Patients and staff may request access to their information or make changes to their information at any time except where we consider there is a sound reason under the Privacy Act or other legislation. We may charge to recover costs in providing access to electronic or paper records. We aim to use accurate, current and complete information or dispose of any unsolicited information or information no longer required.
How safe is your information?
Our practice takes all reasonable steps to protect your personal information from misuse interference and loses and from unauthorised access, modification or disclosure.
In place of your signature please fill in your full name here:
This confirms the date this information is being submitted by yourself:
DD slash MM slash YYYY

Please amend if the date is not correct. Once this page is complete please click on the 'Submit' button.
This confirms the time this information is being submitted by yourself:

: Hours

Minutes

AM/PM

Please amend if the time is not correct. Once this page is complete please click on the 'Submit' button.
Comments
This field is for validation purposes and should be left unchanged.

Online Appointment

Online Appointment request

Online Appointment

Your Feedback

Your Feedback

New Patient Form

Step 1 of 3

PATIENT INFORMATION and HEALTH QUESTIONNAIRE

GENERAL HEALTH INFORMATION

DENTAL HEALTH INFORMATION