412 Old Cleveland Road, Coorparoo QLD 4151 · 07 3398 5885

New patient form

This is everything we need before your child’s first visit. It takes about ten minutes, and it saves as you go — you can stop and come back to it.

Child’s name

Preferred name — what we should call themBirth date

Child’s gender

Address

The most important thing to me is:

Private health insurance / Medicare

Health insurance

Fund:Member No:Reference No:Type of cover:

Is your child eligible for the Child Dental Benefits Scheme?

Medicare numberMedicare ref — the number beside your child’s nameExpiry date — month & year

Your answers are saved on this device as you go, so you can come back to them. They are held in your child’s record and seen only by the team caring for them.