74 High Street, Northcote, Melbourne 3070
(03) 9489 9489
info@bytesofnorthcote.com.au
Contact Us
a
M

New patient?

Here at Bytes of Northcote, we aim to reduce our use of paper as much as possible. If you are a new patient, you can either arrive 10 minutes early for your first appointment to fill out a digital ‘new patient register’ or you may fill it out in the comfort of your own home online.

    Patient Details

    Full Name (required) *

    Date of Birth *

    Occupation

    Phone *

    Address

    Country

    State *

    Suburb

    Postcode *

    E-mail *

    Medicare No (Child Dental Benefit Scheme only)

    Health Fund

    Member Number

    Patient ID

    Emergency Contact Name*

    Emergency Contact Phone*

    Medical History

    Please indicate if you have any of the following...

    Descriptions for Ticked Boxes Please write in this box the answered to the boxes you have ticked.

    Do you have any other condition(s) not mentioned? (Please List)

    Have you been in hospital in the past 2 years? If so, please provide details

    Please list any medicine you currently take

    Dental History

    Please indicate if you concerned or experiencing any of the following dental problems?...

    Reason for Appointment

    How long since your last check up?

    On a scale of 1-10 (10 being completely happy) how happy are you with your teeth

    Is there anything you would like to improve about your teeth/smile?

    How did you hear of us?

    Todays Date*

    TERMS AND CONDITIONS

    a. I certify that the health information provided is complete and accurate to the best of my knowledge. I agree to inform the dentist of any changes to my health or medications at subsequent appointments.

    b. I understand my data is confidential and will only be used for my clinical care or shared with other healthcare providers as legally permitted under Privacy Act guidelines.

    c. I accept responsibility for payment of services at the time of treatment and acknowledge that cancellation fees may apply without 24–48 hours' notice.

    d. By signing, you acknowledge you have read and accepted these terms.