Dental Questionnaire

* Complete the below for another 25% Discount!

Please enable JavaScript in your browser to complete this form.

PLEASE NOTE!

1. Questions appear under the answers.

2. The questionnaire is under live construction and testing.

3. If the answers do not make sense to you, just select any answer, and the dentist will review and update it during your consultation.

Regards Dr Denver Maloney

COMPLETED BY:
Who completed this form?

Patient Details

We are committed to maintaining patient confidentiality, so please do not provide the full name of the patient.
What is the patient's age in years?
This email is used to send you essential information about the patient's dental care. We may also use it to refer specialists as needed.
PATIENT STATUS:
APPOINTMENT BOOKED:
How did you set your dental appointment?
REASON FOR APPOINTMENT:
Select the procedure you want at your dental appointment. Select all that apply.

Dental Status

Let's get some general details about oral health.

ORAL CONDITION:
Which of the above do you have? Select all that apply.

Dental Insurance & Government Schemes

Let's get details about private health insurance and government-funded dental care schemes.

GOVERNMENT-FUNDING:
Does the patient qualify for a government-funded dental care scheme?

Private Health Insurance

MOBILITY AID:
Are you using a mobility aid?
minor oral surgery

OPG Radiograph General Screen - All Patients

lat ceph radiograph

Lateral Cephalogram for Orthodontic Consultation

Thank You!

Sharing your dental history enables the dentist to focus on your unique needs and experiences while providing dental care that meets your unique needs.

See you soon,

Riverina Dental Albury Team

Guarding Patient Confidentiality: Our Top Priority

Discover How We Safeguard Patient Confidentiality

Safeguarding Patient Confidentiality

At Riverina Dental Albury, we uphold patient confidentiality and privacy in all our services, including online form submissions. When you submit forms through our website, rest assured that we take the utmost care to ensure the security and confidentiality of your personal information.

We employ state-of-the-art security measures to safeguard the data you provide, and our staff are trained to handle patient information with the highest level of discretion and professionalism. Our top priority is your privacy, and we adhere to all relevant privacy laws and regulations to protect sensitive information.

It’s important to note that we do not use personal identifiers such as full names in these forms. By omitting personal identifiers, we further enhance the confidentiality of the information you submit. Your privacy and anonymity are central to our commitment to maintaining the highest standards of patient confidentiality.

By submitting forms online, you can trust that your details, medical history, and other information will be handled with the strictest confidence. Our commitment to patient confidentiality extends to all interactions with our practice, whether in person or online.

If you have any concerns about the privacy and security of your information when submitting forms online, please do not hesitate to contact us. We are dedicated to providing you with the highest standard of care, including ensuring the privacy and confidentiality of your personal information. Thank you for entrusting Riverina Dental, Albury, with your dental care.

Yours sincerely

Dr Denver Maloney BDS (Syd) 1989

Dental Surgeon | Practice Principal

* The 25% discount applies to your standard consultation fee; it does not apply to any treatment provided at the appointment.