Browse through our selection of articles that feature tips on maintaining a better smile, success stories and other facts about your Oral Health.
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August 9th, 2017
Date of referral (required)
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Dr Sheng ZhangDr Mark WorthingtonDr Sara Stockham
Dear Dental Artistry, please assess/treat the following patient:
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ACC related (required) YesNo
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Please email all relevant historical treatment notes and imagery to reception@dentalartistry.co.nz. If your referral is ACC related, a team member will contact you with the ACC preferred digital template to use for sending patient records.
Thank you for your referral.
Title (select one) (required) DrMrMrsMissMsnone
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Medical Doctors Name Referring Dentist’s Name
Doctor's Practice Name Referring Dentist’s Practice Name
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1. Are you receiving any medical treatment at the present time? YesNo
Details
2. Are you routinely taking any medicine tablets, dietary supplements, capsules or drugs? YesNo
3. Have you experienced any unusual effects/allergies from any tablets, injections or anesthetic? YesNo
4. Have you ever had any of the following? If so, please tick as appropriate:
Rheumatic Fever Heart Murmur Cancer or Chemotherapy Heart Trouble or Surgery Asthma Arthritis High Blood Pressure Diabetes Auto Immune Illness Bleeding disorder HIV
Kidney trouble Latex Allergy Angina Gastric problems Serious Childhood Illness Pacemaker Fitted Epilepsy Severe headaches Hepatitis – Specify type A, B, C Hay fever Drug dependency
5. Have you had any prosthetic surgery? (I.e. Heart Valve or Hip/Knee Replacement) YesNo
Details (If yes, refer to question 6)
6. Has your surgeon advised you that you require Antibiotic Cover for dental treatment? YesNo
7. Women, are you pregnant? YesNo
If so, how many weeks?
8. Women, are you breastfeeding? YesNo
9. Do you smoke cigarettes? YesNo
If yes, how many per day?
1. Approximate date of your last dental visit?
2. Have you ever experienced any excessive bleeding or bruising from dental treatment or any cuts/scratches? YesNo
3. What is the purpose of today’s visit?
4. Please tick as appropriate the issue you are having
Toothache Missing teeth Lost filling or cavity Rapidly decaying teeth Broken or worn teeth Loosening teeth Unsatisfactory denture Discoloured teeth or restorations Difficulty or discomfort when chewingFood trapping Cold sores
Unpleasant breath, odour or taste Sore or bleeding gums Sounds or clicking from the jaw Pain in face or jaw joints Grinding or clenching of teeth Crooked or poorly aligned teeth Bad appearance Mouth ulcers Dry mouth Sensitive teeth to either extreme temperature or sweets
5. Would you like to have whiter teeth? YesNo
6. Would you like to change the appearance of your teeth, and if yes, what would you like to change? YesNo
Please provide details
7. Do you become anxious or uncomfortable when you are having dental treatment? YesNo
8. Have you had previous Orthodontic Treatment? (i.e. braces) YesNo
9. Have you had previous Oral Surgery? YesNo
10. Have you had previous Periodontal Treatment? (i.e. specialized gum Treatment) YesNo
WebsiteGoogle AdGoogle ReviewAnother patient/friend?Other, please specify
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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.
