New Patient FormConfidential history sheetName Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Address Street Address City ZIP / Postal Code Home phoneDate of birth MM slash DD slash YYYY PhoneEmail Occupation & EmployeerBusiness PhoneBusiness Address Street Address City ZIP / Postal Code Name of Person responsible for FeesPhoneHow did you find out about our practiceFriend / Partner / Work Colleague / Insurance Fund / GooglePlease details the search heading usedE.g Invisalign, Dentist CBD etcDo you have Dental Insurance Yes NoWhat fundHave you ever had any of the following Rheumatic Feaver Diabetes Heart Problems Hepatitis, HIV Osteoporosis / HRT Epilepsy Kidney Disease High Blood Pressure Artificial Hip/ Knee Cancer (any kind) Asthma Excessive Bleeding Reaction to Anaesthetic Pacemaker, Heart ValvePlease detail any other medical/dental problemsAre you allergic to any medicationAre you taking any medicines Yes NoPlease detailEspecially Bisphosphonates such as Fosamax, AltonenDo you smoke Yes NoHow many per dayLadies, are you pregnant Yes NoHave you every had any problems with dental treatmentDo you usually have Local Anaesthetic for Dental Treatment Yes NoWho is your medical practitioner