New Patients - Sunshine Coast Dentist, Sunshine Coast Dental

Welcome to Buderim Dental Practice!

As a new patient, it can be daunting providing the required information for when you come in for your appointment. Here at Buderim Dental, we make it easy for you!

For your convenience and at your discretion, you are now able to fill out a New Patient Form online (see below) before you come and see us at our Buderim dental practice. Any information supplied in this form will be kept strictly confidential.

You can either fill in our new patient form on arrival (please arrive 10 – 15 minutes early to do this) or click here to print a PDF copy and fill in a ‘New Patient Form’ which you can bring with you to your appointment, fax or email us the form to:

Fax: (07) 5453 7522
dentist@buderimdentalpractice.com.au

or you can now fill in the form below and submit it online right away!

Please note, if you require dental attention after hours, we do offer an emergency after hour service. To contact us anytime after hours, call (07) 5453 7022

(* Indicates required fields)

Fill out our New Patient Form online now and save time!

Title *

First Name *

Last Name *

Date of Birth

Email Address *

Home Address

Home Phone *

Mobile Number

Work Number

Health Fund

If Yes, Name of Health Fund

Preferred Method of Contact

Occupation

Emergency Contact Name

Emergency Contact Phone

Preferred Appointment Day

Preferred Appointment Time of Day

Preferred Time

Are you taking any medication, drugs or pills?

If yes, please list names:

Please list any known allergies (medications, penicillin, latex etc.)

Have you had any abnormal reactions to local or general anaesthetic?

If yes, please explain details:

Do you normally require antibiotic cover before dental treatment?

If yes, why?

Have you ever had or currently have the following:

Congenital Heart Disease

A Heart Murmur

A Mitral Valve Prolapse

A Heart Pacemaker

Tuberculosis

Rheumatic Fever

High Blood Pressure

Radiation Therapy

Liver Disease

Leukaemia

Transplanted Marrow

Arthritis / Rheumatism

A Stroke

Any Artificial Joints

Epilepsy / Seizures

Diabetes

Hepatitis / HIV

Nervous / Anxious

Asthma

Sinus Trouble

Women: Are You Pregnant?

If yes, how many weeks are you?

Please list any concerns or problems you have with your teeth or mouth:

How did you hear about us?

If another patient, please name

Did you hear about us any other way? Please explain

I have answered all questions honestly and to the best of my knowledge *

I understand the above info is necessary to provide with dental care in a safe & efficient manner *

If required, I consent to the release of relevant information to you from my health provider. *

I will notify the dentist of any change in my health or medication. *

Date this form was submitted

Please Enter the Code You See: