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Smile Dental Patient Details
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First Name
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Your answer
Last Name
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Your answer
Date of Birth
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Your answer
Address
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Your answer
Suburb
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Your answer
Mobile number
*
Your answer
Personal email
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Your answer
Chemist/Pharmacy email
*
Your answer
Covid - 19
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Tick all that apply
I travelled overseas in the last 14 days
I was in a close contact with a suspected/ confirmed case
I have/ had symptoms of Covid - 19 (i.e: Fever, Shortness of breath, Coughing)
None of the above
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Medical problems?
*
Tick all that apply, please add anything on others section
Heart disease
Liver disease
Kidney disease
Diabetes
Hepatitis B/C
Asthma
Rheumatic Fever
Anaemia
Joint replacement
HIV/AIDS
None of the above
Other:
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Allergies/ Adverse reaction to medication?
*
Your answer
Are you pregnant?
*
Yes
No
Maybe
N/A
Reason for pain relief?
*
Swelling
Toothache
Pain in my gums
Accident/ trauma
Other:
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