Patient information form and Medical history

Patient Information and Medical History Form

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This form is also able to be downloaded here Patient Information Form

Title. Mr / Mst / Mrs / Ms/ Miss/ Dr/ Other________________
Name_____________________________________________________________________________ DOB________________________
Address___________________________________________________________________________Post Code_________________
Home Ph______________________Mobile Ph__________________________Email______________________________________
Employer______________________________________________________Occupation____________________________________
How did you hear about us?__________________________________________________________________________________

Medical Dr Name and Practice-_______________________________________________________________________________
List any medications you are taking_________________________________________________________________________
________________________________________________________________________________________________________________
Are you allergic to anything?_________________________________________________________________________________
Please tick any of the following conditions you may have:

󠅌 Asthma
󠅌 Chest or lung disease
󠅌 Heart Murmur
󠅌 Rheumatic fever
󠅌 Other heart problems
󠅌 High Blood Pressure
󠅌 Stroke
󠅌 Epilepsy
󠅌 Diabetes
󠅌 Kidney problems
󠅌 Liver problems
󠅌 Hepatitis
󠅌 Gastric problems
󠅌 Bleeding problems
󠅌 Depressive illness
󠅌 Radiotherapy
󠅌 AIDS/HIV
󠅌 Joint replacement
Date placed__________________

Any other conditions not listed_______________________________________________________________________________
Do you smoke?________________________Any drug or alcohol addictions?_____________________________________
Women- are you pregnant? Y / N If yes what trimester?__________________________________________
Name and contact number of emergency contact___________________________________________________________
Occasionally photos may be taken of your teeth (not your face) – are you happy for these photos to be used on the website? Y / N

By signing this form, you are accepting full financial responsibility for dental treatment (except when covered by the DHB) and that payment is due at the time services are provided. Unpaid accounts will incur additional charges.
Health and safety – Our dental chairs are rated hold to 120kg, we accept no responsibility should injury occur if you are over this rated weight.
Signed__________________________________________________________________________________Date______________

Reviews

One Dental - Stoke

4.5

Based on 35 reviews

review us on

Haylee Milham

00:49 29 Jul 22

I'm quite anxious about dental visits, the team at one dental were so lovely. Genuinely felt looked after - they helped to fix my problem quickly and painlessly. Thanks for providing such kind, thoughtful service and care.

Tayler Barkle-Barnett

22:54 28 Jul 22

I highly recommend going and seeing Justin at One Dental! Really professional and such a friendly guy. I recently got a filling done and have had the same tooth filled twice before at other practices. Justin explained the process and gave me multiple options. I went with his recommendation which was actually cheaper. He did an amazing job, it looks like a brand new tooth!The receptionist was also very friendly and understanding when I had to rebook because I was in covid isolation. I will definitely be back if I need more treatment. Many thanks! 5 stars!

Erina Tye

08:15 19 Jun 22

Justin and an assistant came in on a Sunday to provide me emergency service when I had a sports injury to my teeth. He was amazing and I was so appreciative of him and his team for helping me out when they don't normally work! They were friendly, informative and I was completely at ease. Thank you so much!

Justin Sturrock

01:08 26 Apr 22

Highly recommend getting dental work done at one dental. I was recommended by a friend. Staff are informative and helpful. They are very professional which gave me alot of confidence.

Casey

01:36 12 Apr 22

The team at One Dental Stoke are hands down the sweetest people I have come across in the industry. They are welcoming and kind - making you feel very calm and safe in their hands.They offer such a large range of services to suit pretty much everyone and their needs. A huge plus for me was that they offer sedation.Justin is incredibly caring & understanding. He provides nothing but the best treatment. I have severe anxiety and he made me feel comfortable and calm in his care.Both receptionists I have dealt with (via phone and in person) provide only the best customer service. Very knowledgeable & kind women that make you feel at ease leading up to any appointments. Incredibly supportive team that look to help any way they can.I am so glad I came to One Dental Stoke. Thank you again to all of the team for taking such good care of me so far.