New Patient Questionnaire Download our New Patient form and bring it in to your first appointment with us.Download New Patient QuestionnaireAlternatively, fill out the questionnaire below and we’ll have it ready for you when you come in. Name Email Date of Birth Address Suburb State Postcode Purpose of Visit Recommended By Private Health Cover Yes No Have you had any of the following? Heart Problem Blood pressure Artificial joints Rheumatic fever Circulatory problems Radiation treatment Excessive bleeding Excessive bruising Stomach ulcers Sinus trouble Tumour history Allergies to anaesthetics Allergies to penicillin Allergies to medications Allergies to latex Anaemia or other blood disorders Diabetes Asthma Hepatitis A, B, C, D or E Epilepsy Liver or kidney problems TICK HERE IF NONE APPLY Any Additional Information SUBMIT