New Patient Info

New Patient Form

At Wellard Village Dental we strive to provide you with the highest possible care. To do this we need to collect personal information from you that include contact details and matters pertaining to your general health, both past and present.  Without this information it is difficult for your dentist or hygienist to plan your care properly.

Please be assured that this information is maintained in accordance with State and Federal Privacy Legislation. If you would like any further information about how we use and protect your personal information, please ask one of our staff. Click here for our privacy policy.

If you don’t wish to complete the form online, you can download the PDF version here.

  • Patient Information

  • Next of Kin

  • In case of an emergency whom should we contact?

    Please indicate if different to next of kin.

  • Reminder System

  • Dental History

  • Please tick any dental concerns you have?

  • Medical History

  • How did you hear about us?

  • Keep Informed

  • Captcha

  • Consent for Services