New Patient Registration

New Patient Registration Form

Complete the form below to register as a new patient.


    First Name*:

    Last Name*:

    Email Address*:

    Date of Birth*:

    Cell Phone Number*:

    Work Phone Number*:

    Home Address*:





    Medical History *: Nil ConditionsLow Blood PressureHigh Blood PressureHeart ProblemsRheumatic FeverProlonged BleedingJoint ReplacementsBone DiseaseCancerHIVHepatitisAsthmaDiabetesEpilepsyAnxiety DisordersPregnantSmokerAllergies

    Please Specify:

    Do you have any medical conditions not listed? Please list here:

    Who may we thank for referring you to us?:

    When was your last visit to the dentist?:

    Why have you booked an appointment?*:

    What is your favourite music to listen to?*:

    Are you or have you ever taken any bisphosphonate medications?*: YesNo

    DISCLAIMER: I hereby accept responsibility for payment of fees in full on the day of treatment. I understand I will be charged a fee of $50 if I fail to provide 24 hours notice of cancellation for all appointments

    Please state name in full*:


    Call The Dentist

    Day Time (02) 9232 6367

    After Hours 040 6986 909

    Office Location & Hours

    Sydney NSW 2000

    Mon & Thu:  8am-7pm
    Tue, Wed & Fri: 8am-5pm
    First Saturday of the Month: 8am-12pm