Is another member of your family a patient at our office?YesNo

Are you pregnant?YesNo

Are you currently taking any medications?YesNo

Have you ever had any of the following?

Do your gums ever bleed when you brush your teeth?YesNo

Previous dental x-rays were taken: *Less than a year agoLonger than a year ago

Have you seen a Dental Hygienist before? *YesNo

A Dental Hygienist is someone who cleans teeth, examines patients for oral diseases such as gingivitis, and provides other preventative dental care. They also educate patients on ways to improve and maintain good oral health. Dental Hygienists work hand in hand with dentists to achieve the best dental care possible.

Consent for treatmentI have completed this questionnaire to the best of my knowledge, and understand that failure to make full disclosure may place ME at undue medical risk. I understand that notes, radiographs (x-rays), photographs or models relating to my treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this. I also give my permission for the practice to use the above contact details to send me appointment and checkup reminders..

Patient signature *

Parent / responsible party’s signature *

Cosmetic Dentistry

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Reconstructive
Dentistry

Orthodontics

Cosmetic Dentistry

General Dentistry

Restorative Dentistry

Reconstructive Dentistry

Orthodontics

Patient Registration Form

Patient Registration Form

Welcome to Wallan Dental

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