New Patient & Dental History Form

We are pleased to welcome you to our practice. Please complete the form. The following information is necessary to enable us to provide you with your best dental care. All information disclosed is confidential.


PERSONAL DETAILS

To complete only if the patient is under 18 years old

REFERRAL INFORMATION
MEDICAL HISTORY:


























DENTAL HISTORY



















CONSENT FOR SERVICES

• I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetics as indicated and I will assume responsibility for the fees associated with those procedures.

• I understand that the practice requires at least 48 hours notice if I need to cancel my scheduled appointment and hat a cancellation fee may apply.

• I am aware that payment is required on the day of treatment.

• We provide as a courtesy to our patients a preventative recall program that offers a recall reminder if you have not been to the practice in 6 months.

We offer Interest Free Plans – No Interest Ever!

affordable dentistry
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We accept EFTPOS, all major Credit Cards as well as HICAPS, MBF, Medibank Private, HCF & All major health funds.
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We are now accredited to NSQHS Standards and HDAA.
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NEED DENTAL ADVICE? JUST ASK US A QUESTION. (replies during business hours)

CONTACT INFO

Norlane Dental Surgery

Address: 124 Sparks Rd, Norlane, VIC 3214

Phone: (03) 5278 2666

OPENING HOURS

Mon:

Tue-Fri:

Sat:

Sun: Closed

PARKING/PUBLIC TRANSPORT

There is ample free car parking onsite

LOCATION

Norlane Dental Surgery is located in Geelong near North Shore only minutes away from North Shore Football Club, Northern Bay College and Water World

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