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如有任何疑问，建议，信息，咨询或更多，请在下面给我们留言，发电子邮件给我们info@painfreedentistsydney.com.au或给我们打电话。如果后小时的紧急是，请致电0458 030 177

Send Us a Message

New Form

Name *

Name

First Name

Last Name

Email Address *

Phone *

Message *

Thank you!

Pain freE dentist SYDNEY

Shop 1, 1 Hornsey St,

Rozelle, NSW 2039

(02)9818 8887

停車處

可在悉尼诊所香雪街免费停车场

新病人问卷调查

为了帮助我们让您以最便捷的方式最好的治疗方法，我们的快速问卷调查将帮助我们确定最佳行动过程

Questionnaire

Medical Details

Full Name *

Full Name

First Name

Last Name

Date Of Birth

YYYY

Address *

Phone

(###)

###

####

Email Address

Preferred Contact Method

Occupation

Healthfund

Healthfund Name

Healthfund Number

Medicare Number

Checkup Reminder

6 Months

12 Months

Never

How did you hear about us?

Google

Yellow Pages

Newspaper

Another Website

Advertisments

Friends or Family

Facebook

Gumtree

Online Deals

Radio

Google Review

Pamphlet Drop

Other

Do you currently have, or had, any history of:

Heart Disease

Asthma

Epilepsy

Lung Disease

Blood Disease

Diabetes

Prosthetic Heart Valves

Heart Murmur

Hepatitis A, B, or C

Aids/HIV

Kidney Disease

Liver Disease

Pacemaker

Radiation Therapy

Rheumatic Fever

Bone Disease

Stroke

Tuberculosis

Excessive Bleeding

Cancer

Chemotherapy

Smoke

Artificial Joints

Sinus Problems

Other Illnesses?

Are you taking any medications?

Are you currently, or have a history of taking medication containing Bisphosphonate?

Have you been hospitalised recently?

If Yes, please explain why?

Are you allergic to penicillin?

Any other allergies?

Are you pregnant?

Have you ever had BOTOX or Fillers done?

if yes, please write the amount of units used

Dental History

Please describe what you would like to achieve from your visit today?

When was the last time you visited the dentist?

YYYY

Are you concerned about or experiencing and of the following dental problems? (tick as many as you think applies to you)

Sensitivity to hot or cold

Food trapping between teeth

Pain when chewing/eating

Staining of your teeth

Discoloured fillings

Chipped or rough fillings

Bleeding gums

Bad breath

Grinding your teeth

Head/neck ache

Clicking or pain in jaw joints

Snoring

Are you concerned with: (tick as many as you think applies to you)

Existing crowns, bridges or dentures

Ability to eat

Gaps between your teeth

Missing teeth

Crooked teeth Silver fillings (amalgam)

Previous dental treatment

Wisdom teeth pain

Smile makeover

Do you want to discuss whitening your teeth with us?

Thank you! One of our specialists will be in contact shortly.

Pain Free Dentist, Shop 1, 1 Hornsey St, Rozelle, NSW 2039(02) 9818 8887info@painfreedentistsydney.com.au