Online Patient Questionnaire-Bays Dental

Patient Health Questionnaire

Please complete the form below
First Name*
Surname*
Gender*
Phone Number

Area CodePhone Number
Occupation*
Mobile Number*

Area CodePhone Number
Date of Birth*

DayMonthYear
Address*

Street Address

Street Address Line 2

CitySuburb

Postal CodeCountry
E-mail Address*
NHI Number
School (if under 18 years)
Full name of school
Medical Insurance Name
example: Southern Cross
Medical Insurance Membership Number
example: membership number 123123123
Insurance anniversary date
Does your medical insurance include dental cover?

YesNo
If YES, please indicate the $ amount you are covered for
Have you previously attended our practice?*

YesNo
Have you previously attended our practice?*

YesNo
We use the above contact details to remind you of your appointments/alert you when you are due to book. It’s also used to notify you of special promotions or competitions via our newsletter. **

YesNo
How did you hear about us?*

GoogleWebsiteRadio- The BreezeRadio- Life FMRoad Sign/Drive PastPhone Book/Yellow PagesMail Box/FlyerKorean Magazine/NewspaperSocial Media/ FacebookAnother PatientOther
Would you like more information about:

Teeth WhiteningStraightening TeethReplacing Missing TeethBad Breath (Halitosis)Other/NoneOther
Name of your last dentist
When was your last dental visit?
Reason for your visit today?
Emergency Contact Details
Emergency Contact's Name*
Emergency Contact's Number*
Emergency Contact's Relationship to you*
example: wife/ partner/Mother
Medical Questions
Medical Doctor's Name
Clinic Name
Doctor's Phone Number
Are you taking any medicine tablets, capsules or drugs?*

YesNo
If Yes, please provide full medication list below?
Are you aware of ANY allergies or adverse reactions that you have (eg Latex, anaesthetic)*

YesNo
If Yes, please list below?
Have you been a patient in hospital during the past two years?*

YesNo
If Yes, please provide details below?
Are you receiving any medical treatment at the present time? *

YesNo
If Yes, please provide details below?
Have you had any prosthetic surgery (eg heart valve, hip replacement etc)*

YesNo
If Yes, please list the type of surgery AND year you underwent the surgery:
Women: Are you pregnant?*

YesNoMaybe
If Yes, please list how many weeks/months?
Do you smoke?*

YesNo
If Yes, how many cigarettes per day?
Have you ever had, or been treated for any of the following conditions. Please tick "yes" or "no"
Heart trouble?*

YesNo
High Blood Pressure? *

YesNo
Blood Disorders?*

YesNo
Anaemia?*

YesNo
Rheumatic Fever?*

YesNo
Asthma? *

YesNo
Bronchitis? *

YesNo
Gastric Reflux? *

YesNo
Stomach Ulcer? *

YesNo
Stroke? *

YesNo
Sinusitis?*

YesNo
Allergies?*

YesNo
Diabetes?*

YesNo
Hepatitis?*

YesNo
Arthritis? *

YesNo
Epilepsy?*

YesNo
Fainting or Dizziness?*

YesNo
Latex Sensitivity?*

YesNo
Epilepsy?*

YesNo
Do you have or are you at risk contracting any of the below:
Hepatitis B *

YesNo
Hepatitis C*

YesNo
HIV*

YesNo
Although rare, accidental injury to staff can occur during handling of used instruments. If this happens during the course of your treatment, our practice requires both patient and staff member to undertake blood tests. Do you agree to a confidential blood test?*

YesNo
AGREEMENT Our Commitment to you: At all times we will provide you the very best dental care available in a modern, friendly environment. As a patient at Bays Dental, your well-being is our first priority. Your details are kept safe (as per the Privacy Act) and is only collected with the purpose of providing you with the best and safest possible treatment and to assist in the administrative aspects of care-giving (as required by the Dental Council of NZ) Your Commitment: I, the undersigned, agree to be responsible for payment of all services rendered on my behalf or on behalf of my dependents. I understand that payment is due at the time of treatment, unless other arrangements have been finalised. A 15% fee may be added to outstanding amounts. If required for debt collection, I understand that any costs incurred while debt collecting will be on-charged to me and that a check of my credit history may be made, and/or my details may be passed to a third party. I understand that by making appointments with Bays Dental, I am agreeing to attend the appointments or to give a minimum of 24 business hours’ notice of cancellation of appointments. If I fail to attend an appointment, a ‘no show’ fee of $50 per half hour of the appointment may be charged.*

Yes
Electronic Signature: Patient/Parent/Guardian*
Should be Empty:

Patient Health Questionnaire

Emergency Contact Details

Medical Questions