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New Patient Enquiry Form

Details

Name*
Address*
Date of Birth*

Your Dental Health

What type of treatment are you interested in?*
Select all that apply

Tooth replacement (Implants, Dentures, Bridges)

Replacement type*

Implants

Has the tooth / teeth been removed?*
Do you have any scans or radiographs related to this?*
Please remember to bring these to your consultation

Dentures

Denture Details - Is this?*
Denture Replacement
Denture Replacement - Upper Details 1*
Denture Replacement - Upper Details 2*
Denture Replacement - Lower Details 1*
Denture Replacement - Lower Details 2*
Do you already have missing teeth?*
Missing Teeth

Bridges

Do you have an existing bridge?*
Has the tooth / teeth been removed?*
Do you have any scans or radiographs related to this?*
Please remember to bring these to your consultation

Orthodontics / Tooth Straightening

What type of braces are you interested in?*
Would you describe your treatment need severity as:*
Crooked (twisted / overlapped teeth) severity*
Crowded teeth severity*
Spaced teeth severity*
Protruding (sticking out) teeth severity*
Uneven smile severity*
Have you had braces in the past?*

Cosmetic Dentistry

What are your main concerns?*

Endodontics (Root Canal Treatment)

Are you currently in pain?*
Have you seen a dentist that has diagnosed the treatment required?*
Do you have your own general dentist?*

General Dentistry

What treatment are you interested in?*

Sedation

Please be aware that there is specific criteria you must meet in order to be eligible for treatment under sedation. We are not able to provide sedation for patients under 18 years of age.

Additional Information

Consent*
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