Welcome to Dentist at Healthlink Townsville
Call-Us-Now: (07) 4723 0624
529 Ross River Road, Cranbrook
Townsville, QLD-4814, Australia.
New Patient Form
  Personal Detail
First Name*
Middle Name
Date of Birth*
Phone Number*
Mobile Number*
Home Address*
Email Address

Health Fund
Member Number
Emergency Contact Name*
Their Contact No*.

To complete only if the patient is under 18 years old

Guardian Name
Contact Number

Referral Information

  Medical History
Name of your GP
Your Doctor's Phone No.
Your Doctor's address

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


Artificial joints


Blood Disease




Excessive Bleeding




Heart Disease

Heart Murmur

Hepatitis A, B, C


Kidney Disease

Liver Disease



Radiation Therapy

Respiratory problems

Rheumatic fever

Sinus problems




Psychological Disorders

Do you normally require antibiotic cover before dental treatment?

Are you pregnant?

If yes, how many months?
Have you had any serious illnesses in the last 2 years?

If yes, please provide more information
Do you have any allergies to Penicillin or other drugs?

If yes, please provide more information
Do you suffer from sleep apnoea?

Is your blood pressure

Do you smoke? If so how many per day?

Have you had any abnormal reactions to local or general anaesthesia?

Please list any other known allergies (including latex, foods and preservatives)
Are you taking any prescription or other medications at present?

Please list current medications
  Dental History

Are you concerned about or experiencing any of the following dental problems? (please tick if applicable)

Bad breath

Bleeding gums

Clicking/pain in the jaw joints

Discoloured fillings

Food trapping between your teeth

Grinding or clenching of your teeth

Head/neck ache

Roughness of existing fillings

Sensitivity to hot or cold

Sensitivity when eating

Staining of your teeth

Other... Please describe below

Are you concerned with: (please tick if applicable)

Ability to eat

Crooked teeth or Missing teeth

Discolouration of your teeth

Existing crowns, bridges or dentures

Gaps between your teeth

Previous dental treatment

Silver fillings

Tooth clean techniques (e.g. Brushing)

Your smile

What is the main purpose of your visit today?
How long since your last dental visit?
Does dental treatment make you nervous?

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

Gas (Nitrous oxide-laughing gas)

General Anaesthesia

Intravenous sedation

  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 24 hours notice if I need to cancel my scheduled appointment and
    that a cancellation fee of $50.00 could be incurred if I fail to do so.
  • I hereby consent to the use of any study models, x-rays, computer images and photographs at various dental
    seminars, lectures, and publications that the dentists may author.
  • 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 call service if you have not
    been to the practice in 6 months. Do you wish to receive a phone call from the practice in the event that you have
    missed your recall?
  • Yes I agree

Privacy Policy

  • This information will only be used by the treating dentist in order to deliver your care to the highest standards.
  • It will not be disclosed to those not associated with your treatment without your consent except as provided under the legislation and where we consider you would have a reasonable expectation of us to provide such information.
  • You may seek access to the information held about you and we will provide this access without undue delay. This access might be by inspection of your dental records at the time of appointment or by special access or copying of information at other times.
  • There will be no charge made for requesting this information but there may be fees levied just to cover the costs associated with the processing of this request or the copying of information.
  • We will take reasonable steps to protect this information from misuse or loss and from unauthorised access, modification or disclosure.
  • Our staff are trained to respect these principles at all times.