New Patients · Before Your Visit

New Patient & Dental History Form

We are pleased to welcome you to our practice. Completing this form before your appointment helps our team understand your health and provide safe, appropriate dental care for you. All information you share is treated in confidence.
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Call (03) 5278 2666
  • Strictly confidential
  • Around 10 minutes
  • Saves time at your visit
Norlane Dental

    Your privacy matters. The details below help us care for you safely and are kept strictly
    confidential, in line with Australian privacy requirements. Please complete every field you can — if you are
    unsure about anything, leave it and our team will go through it with you at your appointment.

    01Getting started

    What is the main purpose of your visit today?

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    02About you

    Personal details











    To complete only if the patient is under 18 years old




    03Referral information

    Where did you find us?

    04Medical history

    Your medical history

    This information helps us care for you safely. All answers are confidential.




    Have you ever had any of the following? Please tick those that apply:

    Have you had any serious illnesses in the last 2 years?

    Are you currently taking any medications or tablets regularly?

    Do you have any allergies to Penicillin or other drugs?

    Is your blood pressure normal, high or low?

    Do you suffer from sleep apnoea?

    Do you smoke?

    Do you drink alcohol?

    05Dental history

    Your dental history

    Are you concerned about or experiencing any of the following dental problems? (Please tick as many as it applies)

    Are you concerned with: (Please tick as many as it applies)


    Does dental treatment make you nervous?

    Have you ever had or require the following for dental treatment?

    06Consent for services

    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 that 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.

    Do you wish to receive a recall reminder? *


    [uacf7_signature* patient-signature] By signing you confirm you have read and agree to the consent statements above.


    * Required fields

    Your information is kept private. We will only use it to contact you about your enquiry. We'll be in touch within 1–2 business days.

    We're here to help

    Questions before your visit?

    Prefer to complete this in the clinic, or have something you'd like to ask first? Our Norlane team is happy to help.
    Contact the practice
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    Call (03) 5278 2666
    Location

    Norlane Dental Aesthetics & Implants

    21-29 Princes Highway
    Norlane VIC 3214

    Direct line

    (03) 5278 2666

    Reception is happy to help with enquiries and appointments

    Hours

    Mon – Thu · 8:30am – 6:30pm
    Fri · 8:30am – 5:30pm
    Sat · 8:30am – 4:00pm

    Parking

    Ample free on-site parking

    Easy access from the Princes Highway, Norlane