Patient Information

Dentistry on Parkside provides a premiere service, delivering
results of the highest quality in a relaxing, modern environment

New patient health questionnaire

Please complete our new patient form prior to your appointment, if you have any questions please feel free to call us on 03 308 7472

If you would like to arrange a consultation, or simply wish to know more about our dental clinic services in Ashburton, please Contact Us.



































Next of kin













Person responsible for Account (if not patient)




Medical insurance

If you have medical insurance




Medical practitioner (Doctor)














Are there any other aspects concerning your health that you think we should know about?




Do you consent to the use of your treatment records for education or communication purposes




Do you consent to a topical fluoride treatment if clinically indicated?




Are you receiving any medical treatment at the present time?




Have you ever been in hospital?




Have you ever had any of the following?


Rheumatic FeverEpilepsy / FittingHeart TroubleOpen Heart SurgeryHigh Blood PressureDiabetes - Type 1 or Type 2AsthmaKidney TroubleArthritisGastric ProblemsHepatitis Specify type A, B or CCold SoresBronchitis or Chest ProblemsDepressive IllnessSevere HeadachesDrug DependenceAnaemiaStrokeSinus / Hay FeverRadiotherapy

Are you taking any tablets, capsules, medicines or drugs?







Have you any allergies to medicines that you are aware of?




Do you have an artificial or prosthetic joint?











Have you ever experienced excessive bleeding or bruising from Dental treatment, Cuts or Scratches?Have you ever had contact with the AIDS virus or Hepatitis B virus?Have you ever had a reaction to an anaesthetic?(Women) Are you pregnant at the moment?



Do you take Recreational Drugs







Do you Smoke?










ArnicaSt John's WortGingerGinsengGarlic




Do you wear a medical bracelet?







To my knowledge the above is a true and accurate account of my medical history and personal details.
Agreement to pay: I agree to pay any charges on the day of service. Payment by automatic payment is acceptable if arrangements have been made with the Practice Management BEFORE consultation. If I have claimed to have my treatment covered by a third party, e.g. ACC, Medical Insurance, Community Services and the claim is not accepted within three months I understand that I am liable for the full costs of treatment received. I have read and understand the Terms and Conditions (Full copy of Terms and Conditions available at Reception on request).