Add: 9 Gregory Street, Sandy Bay, TAS 7005, Australia | P: (03) 6223 5514 | F: (03) 6223 3777 | E: click here

New Patient Form

At Prime Dental we strive to provide you with the highest possible care. To do this we need to collect personal information from you that include contact details and matters pertaining to your general health, both past and present. Without this information it is difficult for your dentist or hygienist to plan your care properly.

Please be assured that this information is maintained in accordance with State and Federal Privacy Legislation. If you would like any further information about how we use and protect your personal information, please ask one of our staff for our brochure “Personal Information, Privacy and your Dentist”.

Download the PDF version from here.

Info Evenings

At Prime Dental our dedication and care extends beyond your treatment. With a desire to keep you informed and your smile healthy, we host regular info evenings to outline changes to our practice, dentistry and treatment advances and more. They are an educational, informative and fun opportunity to chat and mingle with like minded people.

Patient Referral Reward

We love knowing so many of our patients recommend our services to family, friends and colleagues. We appreciate this and like to say thanks with a small reward.

Corporate Dental Program

Prime Dental along with DENTAL CARE NETWORK ™ is offering the Corporate Dental Program, providing you with a complimentary $100 service voucher towards your dental treatment if you are an employee of one of our partnered corporate programs.

New Patient Offer

Welcoming new patients to our practice with this exclusive New Patient Offer.

Access for the Disabled

disabled access Access for the Disabled is available via the rear entrance. There is a door bell at the base of the ramp to alert staff to your arrival.

Title:
Surname:*		Given Name:*
Preferred Name:		Date of Birth:*
Address:*		Suburb:*
Postcode:*
Ph (home):*		Mobile number:
Ph (work):
E-mail:*
Yes No To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
Vet Affairs	Gold White	Vet Affairs Card No:
VA Expiry Date:
Name of Private Health Fund (if any)		Position No on card:
Occupation:		Employer Name:

Name:	Relationship:	Phone:
In case of an emergency whom should we contact? Please indicate if different to next of kin.
Name:	Relationship:	Phone:

We remind our patients of their appointments. If you would like us to do this please indicate the preferred means of contact.
SMS	Mobile	Hm phone	Work phone	E-mail


Referral Source:
Referred by another patient who?
Referred by staff who?
Other
Company Referred By who?

Have you had or are you suffering from any of these? (please tick)
Heart Trouble / Surgery Cardiac Pacemaker High blood pressure Low blood pressure Diabetes Hepatitis Rheumatic Fever Arthritis Thyroid trouble Epilepsy Sleep Apnoea Stroke Stomach or digestive condition/reflux Osteoporosis	Nervous Disorders Asthma HIV/AIDS Liver or kidney disease Are you or could you be pregnant Excessive or prolonged bleeding Radiation or chemotherapy Eating disorder Prosthetic implant/joint replacement Organ or bone marrow transplant Steroid therapy Other (specify) Do you smoke?
Are you allergic to anything eg local anaesthetic, latex, penicillin, peanut, etc (please specify)
What medications including natural remedies are you taking?

How do you rate your general health? Excellent Good Poor Fair
Who is your general practitioner?
Telephone: