Suite 603, 8 Elsie Street, Burwood NSW 213402 8188 6688

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New patient form

Completing this before your first appointment saves time on the day. It takes about five minutes.

Your details Full name Date of birth Mobile Email Address Preferred language

Health fund & referral Private health fund (if any) Your regular dentist and practice Were you referred?

Medical history Medical conditions Current medications (including blood thinners and osteoporosis medication) Allergies Smoking or vaping Pregnant or breastfeeding

What would you like help with? I agree to the centre's privacy policy, including that this form is sent by email through a third-party service.

Gum & Dental Specialist Centre · Suite 603, 8 Elsie Street, Burwood NSW 2134 · 02 8188 6688

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