New Patient Form

At Bligh Park Dental we strive to provide you with the highest possible care. To do this we need to collect personal information from you that include contact details and matters pertaining to your general health, both past and present.  Without this information it is difficult for your dentist or hygienist to plan your care properly.

Please be assured that this information is maintained in accordance with State and Federal Privacy Legislation.  If you would like any further information about how we use and protect your personal information, please ask one of our staff for our brochure “Personal Information, Privacy and your Dentist”.

Patient Information
Title:    
Surname:* Given Name:*
Preferred Name: Date of Birth:*
Address:* Suburb:*
Postcode:*    
Ph (home):* Mobile number:
Ph (work):  
E-mail:*
Yes No
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
Vet Affairs Vet Affairs Card No:
VA Expiry Date:    
Name of Private Health Fund (if any) Position No on card:
Occupation: Employer Name:
Next of Kin
Name: Relationship: Phone:


In case of an emergency whom should we contact?
Please indicate if different to next of kin.
Name: Relationship: Phone:
Reminder System

We remind our patients of their appointments.  If you would like us to do this please indicate the preferred means of contact.
How did you hear about us?
Referral Source:    
Dental History

How long is it since your last thorough dental examination?

Please tick any dental concerns you have?
















Medical History

How do you rate your general health?
Who is your general practitioner?
Telephone:
Have you had or are you suffering from any of these?  (please tick)


























Are you allergic to anything eg local anaesthetic, latex, penicillin, peanut, etc (please specify)

What medications including natural remedies are you taking?
Consent for Services

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.

 

Email us click here

Surgery Opening Hours

Mon - Thurs 9:00am - 6:00pm
Friday 9:00am – 5:00pm
Alternate Saturdays
8:00am – 12:00 noon

Our Location

Suites 1 & 2, Bligh Park Medical
& Professional Centre
48 Rifle Range Road
Bligh Park, NSW 2756

find us on google maps now

Parking

Parking is available on site.

Ask our Dentist


Ask one of our experienced dentists a question or arrange a consultation online.

click here for more

New Patient Offer


Comprehensive Dental Assessment includes:

  • Comprehensive Dental Assessment
  • Up to 4 Diagnostic X-Rays (if required)
  • Intra Oral Camera (if required)
  • Treatment Planning
click here for more

Online Patient Form


To complete or download our medical and dental history form before your first appointment.

click here for more

Corporate Dental Program


Bligh Park Dental & DENTAL CARE NETWORK™ are offering a dental program which provides an exclusive voucher of $100 to be redeemed for dental treatment if you are an employee of one of our partnered corporate programs.

click here for more