Confidential Patient Questionnaire

MM slash DD slash YYYY
Email authorisation

Emergency Contact

Medical History

1. Are you receiving any medical treatment at the present time?
2. Are you routinely taking any medicine tablets, dietary supplements, capsules or drugs?
3. Have you experienced any unusual effects/allergies from any tablets, injections or anesthetics?
4. Have you ever had any of the following? If so, please tick as appropriate:
5. Have you had any prosthetic surgery? (I.e. Heart Valve or Hip/Knee Replacement)
6. Has your surgeon advised you that you require Antibiotic Cover for dental treatment?
7. Women, are you pregnant?
8. Women, are you breastfeeding?
9. Do you vape or smoke cigarettes?

Dental History

2. Have you ever experienced any excessive bleeding or bruising from dental treatment or any cuts/scratches?
3. Please tick as appropriate the issue you are having
4. Would you like to have whiter teeth?
5. Would you like to change the appearance of your teeth, and if yes, what would you like to change?
6. Do you become anxious or uncomfortable when you are having dental treatment?
7. Have you had previous Orthodontic Treatment? (i.e. braces)
8. Have you had previous Oral Surgery?
9. Have you had previous Periodontal Treatment? (i.e. specialized gum Treatment)

Referred By

How did you find out about us?

Our Practice Policies

We ask that all patients make full payment on the day of their appointment. We will provide you with a written estimate for your dental treatment after your initial appointment. A fee may be charged for missed appointments, appointments cancelled with less than 2 business days’ notice or late arrival to appointments. Unpaid accounts may attract interest and debt collection fees. I agree for my de-identified photos being used for educational or marketing purposes

Our aim is to provide you with a beautiful smile, a comfortable and efficient bite and excellent oral health

At Dental Artistry we’re dedicated to providing you with exceptional dental treatment in a practice that adheres to the most stringent safety and quality measures.

Our dentists, and patient support team are committed to treating you with kindness and respect.

Tell us about your dental goals and we’ll do our utmost to help you achieve them.

09 524 4541
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