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New Patient Questionnaire

    Preferred Title*

    If under 18: Please provide

    Do you have dental insurance cover?

    In case of an emergency, who can we contact

    Please tick any of the following that applies and provide any appropriate details

    Cardiovascular:

    Respiratory:

    Allergies:

    Other:

    Are you currently taking any medications?

    If applicable, are you currently pregnant?

    Do you smoke or vape?

    Have you ever had contact with:

    HIV virus

    Hepatitis B virus

    Hepatitis C virus