Forms New Patient QuestionnaireMedical History UpdateTooth Extraction: Request an AppointmentPeriodontal Treatment: Request an AppointmentDental Hygiene: Request an AppointmentTooth Extraction: Medical HistoryPeriodontal Questionnaire Periodontal Treatment Registration Periodontal Treatment Registration Enter your details here if you would like to register for a consultation and possible treatment. Name* PrefixFirst NameLast Name Phone Number* Please enter a valid phone number. Email* example@example.com Date of Birth* -Day -MonthYearDate Back Next Has Periodontal Treatment been recommended to you?* YesNo If so, by who? Do your gums bleed when you brush your teeth?* YesNo Do your gums bleed even without brushing?* YesNo Are you prone to having swollen & puffy gums?* YesNo If so, where? Have you ever had gum boils?* YesNo If so, where? Have any of your teeth become loose over time?* YesNo If so, which teeth? Are you aware of any gum recession?* YesNo If so, where? Do you find you get food stuck in between your teeth?* YesNo If so, where? Do you get tender gums?* YesNo If so, where? Do you get a bad taste in your mouth?* YesNo Do you suffer with bad breathe?* YesNo Have you noticed a change in the way your teeth bite together over the past couple of years?* YesNo Have you noticed any drifting of your teeth over the past couple of years?* YesNo If so, where? Do you suffer from tooth sensitivity to hot, cold, sugar? HotColdSugarNone of the above Where do you feel this sensitivity? How often do you see a hygienist? When was your last visit? Has your dentist/hygienist ever carried out deep cleaning under the gum? This usually requires injections YesNoNot Applicable What type of toothbrush do you use?* Electric ToothbrushManual Toothbrush How often do you brush your teeth? How often do you use dental floss? If you use TePe Brushes, how often do you use them? If you use TePe Brushes, which colours do you use? How often do you use mouthwash/gels? Please write any other details regarding gum symptoms that you feel we should know Submit Should be Empty:
