New Patient Form

New Patient Form

Contact Information:

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Under 18 Years Of Age Complete The Information Below:

Referal Information:

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Medical History

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Dental History

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Consent For Service

  • I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics as indicated and I will assume responsibility for the fees associated with those procedures
  • I understand that the practice requires a minimum of 24 hours notice if I need to cancel my scheduled appointment and that a cancellation fee of $50.00 could be incurred if I fail to do so.
  • I hereby consent to use of any study models, x-rays, computer images and photographs at various dental seminars, lectures, and publications that the dentists may author.
  • I am aware that payment is required on the day of the treatment.
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166 Main South Road

Morphett Vale, SA, 5162

(08) 8382 2410

Call us today!

Open Hours

Mon/Tue/Thur 8am to 7pm Wed/Fri 8am to 5pm

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