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1311 Pacific Hwy, Turramurra
NSW - 2074

call us02 9449 9366

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Find Us Online

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1311 Pacific Hwy, Turramurra
NSW - 2074

call us02 9449 9366

Request An Appointment Today

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New Patient Form (Adult)

Address Information
D.O.B. *
Do you have a Dental Health Fund?
Preferred means of contact
Medical History
Address
Does dental treatment make you nervous? *
Females, are you pregnant? *
Have you ever smoked? *
Have you ever had or are currently suffering from any medical conditions? *
Are you taking any medications? *
Do you suffer from any serious illnesses? *
Have you ever had an adverse reaction to local anaesthetics or other medications? *
Have you ever had Botox™ or dermal fillers? *
Do you snore or have you been diagnosed with sleep apnoea? *
Terms of Acceptance

1. All dental treatment is carried out using the latest techniques, equipment and materials. All equipment is either disposable or sterilised using an autoclave which is validated daily for optimal efficiency.

2. It is the policy of this practice to take diagnostic radiographs (x-rays) at the first examination and specific radiographs (x-rays) as required before certain procedures.

3. Any treatment required will be provided with the patient’s informed consent after all risks associated with the treatment are outlined.

4. All information on this form is considered confidential and is necessary to ensure that the best possible treatment can be provided.

5. Each appointment made is a contract between North Shore Dentistry and the patient. All appointments cancelled with less than 24 hours notice will incur a $100 cancellation fee to help cover costs.

6. An estimate of fees for treatment should be outlined prior to treatment being provided. If you are not sure of estimated fees, please let our Practice Manager or your Dentist know.

7. All fees incurred per appointment must be settled at the completion of that appointment, unless a payment plan has been created with your Dentist or the Practice Manager.

8. Dishonoured cheques will incur a $50.00 dishonour fee.

9. Should any account for any reason become outstanding, then the patient, or person responsible for accounts, will be responsible for all debt collection charges incurred.

10. Should any photographs be taken of you, please confirm if you are happy for these to be used for:

Research Purposes
Marketing Purposes
Date

Request An Appointment Today with North Shore Dental Clinic.

Same day appointments available from your dentist in Turramurra North Shore Dentistry.

Call: 02 9449 9366Book An Appointment

Ask Dr Sasha Rutnam

If you have a question about your oral health, please ask us below. We’d love to help!

sasha-rutnam

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