Congratulations $55 Credit is Yours

Claim another *$55 Credit - Complete the Dental Questionnaire Below

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 STATUS:

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.
APPOINTMENT BOOKED:
How did you set your dental appointment?
REASON FOR APPOINTMENT:
Please select all the dental matters that apply to you.
Describe your dental problem or dental treatment goals in as much detail as possible.

Private Health Insurance

DENTAL INSURANCE:
Do you have health insurance that covers dental treatment?

Patient Mobility

Understanding this information will help ensure our facilities and services are accessible to all patients, and your input will help us provide the best possible care.

MOBILITY AID:
Are you using a mobility aid?

Sensory

Knowing the details about your sensory issues will help us deliver a dental experience that maximises your comfort during your dental visit.

SENSORY ISSUES:
Are there any sensory issues that we need to know about?

DIET

Cavity Risk | Gum Health | Tooth Sensitivity | Systemic Health Link

Understanding your diet assists us in developing a dental care plan that addresses your unique needs.

Managing the consumption pattern of foods and drinks that contain carbohydrates and acids is key to managing optimal tooth and gum health.

Tooth sensitivity can be related to highly acidic drinks or foods and dissolve the hard tooth surface and irritate already sensitive teeth.

Systemic health (whole body health) is closely linked to oral health, so understanding dietary habits can provide insight into potential systemic issues.