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Welcome to Wholistic Dentistry

Please fill and submit the following form prior to attending your appointment

Wholistic Dentistry

 

PH: (02) 6297 8838

6/2 Rutledge Street

Queanbeyan NSW 2620

www.wholisticdentistry.com.au

[email protected]


Thank you for choosing our practice.

In order to serve you properly we will require the following information. All information will be strictly confidential.


BEFORE YOU GO TO THE NEXT SECTION, PLEASE REMEMBER WE RESPECT YOUR PRIVACY.

IF YOU WOULD PREFER TO SPEAK WITH THE DENTIST, THIS IS YOUR RIGHT AND ANYTHING YOU DISCLOSE IS STRICTLY CONFIDENTIAL.

SELECT ANY OF THE FOLLOWING YOU HAVE HAD OR SUFFER ALL THE TIME WITH:


YOUR DENTAL HISTORY


I UNDERSTAND PAYMENT IS REQUIRED AT THE SAME TIME OF TREATMENT. I ALSO ACKNOWLEDGE THIS SURGERY DOES NOT DO ACCOUNTS.