Please kindly provide the following pre-treatment information. The information we collect enables us to provide you with better care. Your privacy is important to us, so all information provided will be kept strictly confidential
TitleMrMrsMsDrMasterMissNo TitleOther
First Name*
Last Name*
Date of Birth*
Preferred Name
Address
Post Code
Mobile Phone*
Home Phone
Email
How would you like to receive an appointment reminder?EmailSMSPhoneMailNone
If you are under the age of 18 please state Father / Mother / Guardian‘s Name
Name of Parent / Guardian
Contact No
Occupation
Business Name
Work Phone
Name
Relationship
What is the purpose of your visit today?
When was your last dental checkup?
Have you had any problems with past dental treatments?
NoYes
Do you have Private Health Insurance?
Fund
Membership No
Reference No
Are you a Veteran Affairs Card Holder?
Card No
How did you hear about this practice?
To whom shall we make your accounts payable?
I have read and understand Beyond Smiles Privacy Policy. I understand that payment is required on the day of treatment.
My preferred method of payment is
CashCredit CardEFT
Patient Signature
Patient / Guardian Name
Date
New PatientCurrent PatientReturning Patient
Respond to me via: PhoneEmail
AMPM
