(02) 8622 3922
info@everybodysmile.com.au
Willoughby, Miranda & Bondi Junction NSW
EverybodySmile logo

New Patients

Tell us all about you

New patient form

You don’t need a doctor’s referral (except for DVA).  Please use the below form to tell us all about you so we can make everything comfortable for you.

New Patient Form

Patient details

Address
Address
City
State
Postcode
Is the patient the person completing this form?

Your details

Address
Address
City
State
Postcode
Is the Emergency Contact / Person responsible, same as above?

Emergency Contact / Person Responsible

Address
Address
City
State
Postcode
plus1 Add another person minus1 Remove

Medical details & history

Do you have Health Insurance?
iCare Participant?
Do you require an iCare report?

Maximum file size: 516MB

Do you have a disability?
Do you have a mental illness?
Do you have a history of causing behavioural harm?

Maximum file size: 516MB

Do you have an Oral Care Plan?
Do you have any other Plans?
(e.g. diet, dysphagia, behaviour, epilepsy, NDIS)

General Medical Practitioner Details

Practice address
Practice address
City
State
Postcode

Visit Options

Need headphones/earplugs?
Fidget toys, stim toys, stress ball?
Music
TV
Chit chat?
Weighted blanket?
Female clinician?
Interested in sedation?
Appointment length preference
I would like a "no-treatment visit" for familiarisation

Dental Details

Dentist's address
Dentist's address
City
State
Postcode
When was your last dental visit?
How often do you usually visit the dentist?
Do you have a history of trauma to the head/neck/teeth?
Do you have jaw joint pain, clicking or locking?
Brushing teeth
How many times per day do you brush?
Do you brush teeth Morning AND Night?
If the dentist is running late, is this going to be an issue?
Do you have any sensory issues?
I can transfer to the dental chair
Do any of the following affect your ability to comply for dental treatment?
Have you had sedation for dental treatment previously?
Would you like us to email images for a social story before the appointment?
Do you have difficulty cooperating due to cognitive impairment or dental phobia?
I agree that the above is a true and accurate record. I understand that The EveryBody Smile Dentistry Practice requires payment on the day of the treatment. Any expenses, costs or disbursements incurred by The EveryBody Smile Dentistry Practice in recouping any outstanding monies including debt collection fees and solicitor costs shall be paid by the responsible party above. I further acknowledge that failure to attend any appointment without notice may also result in a deposit requirement prior to future appointments. I have read and agree with the privacy statement on the end of this document. This form is a guide and you should discuss any relevant conditions with your dentist prior to commencement to any dental treatments.