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

New patient form

It can be filled in by the patient or by someone who supports them. It saves as you go, so you can stop and come back to it, and you can skip anything that does not apply.

Patient’s name

Preferred nameBirth date

Patient’s gender identification

Address

Phone numberParent/guardian mobile number

Contact details

Contact — full name

Relationship to patient — if substitute decision makerEmailPhone numberPreferred contact method:

Private health insurance / Medicare

Health insurance

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

Medicare numberMedicare ref:Expiry date — month & year:

Substitute decision maker details

Does the patient have capacity to make healthcare decisions?

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