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Petone Dental Centre
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PH:
04 8324428
Surname
Given Names
Address
Address Street
City/Town
Date of Birth
School Name(if applicable)
How did you hear of this practice?
Name of GP/Medical Centre/Doctor
Name of Previous Dentist
When did you last visit a dentist?
If yes to serious illness or hospitalised in the last 5 years, please state:
Are you taking any tablets, medicines, pills or drugs? If yes, please list.
If so, how many per day
Have you ever had any allergies to medicines, or other substances (such as Latex)? If so, please list.
Do you have any artificial or prosthetic joint?
- Select -
Yes
No
Have you ever had contact with HIV, Hepatitis B or Hepatitis C?
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Yes
No
Have you ever had an unfavourable reaction to local anaesthetic?
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Yes
No
Women: Are you pregnant now?
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Yes
No
If So how many weeks
Do you currently smoke?
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Yes
No
Do you wish your child/children (aged 13-18) to receive free dental treatment made available under the Ministry of Health Agreement?
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Yes
No
Do you wish to whiten your teeth?
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Yes
No
you wish to straighten your teeth or better your smile?
- Select -
Yes
No
Preferred Method of Communication
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Phone
Email
Sms
Email Address
Phone
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Home
Services
Preventative
Cosmetic
Surgical
Government Funded
Team
Contact Us
New Patient