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6/2 Rutledge Plaza

Queanbeyan NSW 2620

Call us today!

Work days

Mon - Fri / 9 a.m. - 5 p.m.

Email:

[email protected]

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Welcome to Wholistic Dentistry

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

Δ

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.

Choose:

MR

MST

MRS

MS

MISS

First Name

Last Name

Address:

City

State

Postcode

Country

Date of birth:

Email

Home Phone:

Mobile:

Work:

Occupation:

Do you have private health insurance? If yes, which fund?

Next of kin (Name and Phone Number):

Emergency contact other than next of kin (Name and Phone Number):

What is your reason for coming to the surgery?

Whom may we thank for referring you?

What is the name of your medical practitioner?

Name the medicines or drugs you have taken in the past year?

Are you allergic to penicillin, or any other drugs or medicines? Please specify.

Have you ever had excessive bleeding requiring special treatment? YES / NO

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:

Diabetes

Tuberculosis

Headaches

Asthma

Stroke

Epilepsy

Clicking mandible

Shoulder pain

Ankle pain

Neck pain

Backaches

Cough

Mental health problems

Blood transfusion

High blood pressure

Heart mumur

Heart trouble

Congenital heart lesions

Anaemia

Jaundice

Hepatitis

AIDS

Mouth ulcers

Cold sores

Have you ever had any serious illness? YES/NO, Please specify.

Are you pregnant now? YES/NO If YES number of weeks or months?

YOUR DENTAL HISTORY

How long has it been since you have seen a dentist?

What was done?

Did you have any X-rays?

How often did you visit the dentist before then?

How often do you brush your teeth?

How often do you replace your toothbrush?

Do you use dental floss? If yes, how often?

Do you have bleeding gums?

Does food wedge between your teeth?

Do you grind or clench your teeth?

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

Date / Time

Mask Input

Wholistic Dentistry’s goal is to provide a high standard of care to patients, improving their quality of life, with a whole body approach to pain management, dental and preventative health treatment.

Menu

Home
About
SOMA
Case Studies
- Case Studies
Services
Equipment
Forms
Contact
- Contact us
- Parking area

Opening Hours

Monday

9 a.m. - 5 p.m.

Tuesday

9 a.m. - 5 p.m.

Wednesday

9 a.m. - 5 p.m.

Thursday

9 a.m. - 5 p.m.

Friday

9 a.m.- 5 p.m.

Saturday

closed

Sunday

closed

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