Get In Touch Suite 101 Piccadilly Ct, 222 Pitt St,Sydney, Australia 2000Phone: 02 9264 5195 Email: info@anokhidental.com.auOpening Hours:Monday to Thursday 8:30am to 5:30pm. We can’t wait to hear from you! I'm Ready New PatientsNew patients are required to complete the New Patient Form prior to their first appointment with Anokhi Dental. New Patient Form New Patient Form Title * Mr Mrs Miss Ms Dr. Prof. Rev. First Name * Last Name * Date of Birth * MM DD YYYY Address * Street Address * City * State / Province / Region * Zip / Postal Code * Country Phone * Email * Would you like to sign up for our Newsletter? * Yes, please! No, thanks! How did you hear about Anokhi Dental? * From a friend Existing patient Social media Print Google Next of Kin * In case of emergency Next of Kin Phone number * In case of emergency Have you been under the care of a medical doctor or practitioner during the past two years? * Yes No If yes, for what? Doctor / Practitioner Name * Doctor / Practitioner phone number * Have you been a patient in hospital in the past five years? * Yes No Are you taking any medications or drugs now? * Yes No Have you ever taken any bisphosphonate medications? * Yes No Are you taking vitamins or supplements now? * Yes No Are you allergic to any medications, including penicillin? * Yes No Please provide names and dosages if you have answered yes to any of the above Please indicate which of the following you have (or have had) and provide details below: * Heart Disease (angina, heart attack, dysrhythmia, arrythmia) Congenital heart disease (heart murmur, prolapsed mitral valve) Rheumatic Fever/Endocarditis Heart Surgery Artificial heart valve or pacemaker Stroke High / Low blood pressure Bleeding abnormalities (warfarin therapy, haemophilia) Respiratory Disease (asthma, bronchitis, emphysema) Diabetes Thyroid Disease (hyperthyroidism, hypothyroidism, Hashimoto’s thyroiditis, Graves’ disease) Kidney/Urogenital Disease Liver Disease (jaundice, cirrhosis, fatty liver) Digestive Disorders (reflux, leaky gut, Candida, SIBO, constipation) Multiple Sclerosis Osteoporosis Arthritis/Artificial Joints (hip, knee etc) Malignancy Chemotherapy Radiotherapy Surgery Allergies (hay fever, latex) Neurological Disorders (epilepsy, dementia, Alzheimers disease, Parkinson’s disease) Psychological disorders (anxiety, depression) Chronic Fatigue Syndrome HIV / AIDS Hepatitis Tuberculosis Do you smoke or consume alcohol? General Fatigue Daytime Sleepiness Insomnia Irritability Unexpected Weight Gain Sleep apnoea Have you ever had a sleep study? Have you ever seen an Ear Nose Throat Specialist (ENT)? Do you smoke? Do you consume alcohol? Do you use recreational drugs? None of the above apply to me Please provide information if you have ticked "Yes" to any of the above or if you have any disease or condition not listed: Ladies are you: * Taking birth control Planning pregnancy Breastfeeding Undergoing IVF Not applicable to me Please provide information if you have ticked "Yes" to any of the above or have a condition not listed: What is the reason for your visit? * When did you last visit a dentist? * How often do you have dental examinations? * Last dental cleaning? * Last full mouth x-rays? * How often do you brush your teeth? * How often do you floss? * What oral care products (toothpaste, mouthwash, etc) do you use? * Do you have any dental problems now? * Yes No If yes, please describe: Please select all that apply: * My gums bleed or hurt I experience bad breath or a bad taste in my mouth I noticed loose teeth or a change in my bite Food gets caught between my teeth I experience mouth ulcers, cold sores or any other lesions I have experienced dental infections I have had dental decay or fillings I have had any crowns or bridges placed in my mouth I have had root canal treatment I have dental implants I experience difficulty chewing I am missing teeth I wear dentures I clench or grind my teeth I have had my teeth ground or bite adjusted I have (or had) a bite plate or mouthguard I experience clicking or popping of the jaw I get headaches, neck or shoulder tension I have tired jaws, especially in the morning I am sensitive to anaesthetics and/or dental materials I am dissatisfied with the appearance of your teeth I feel nervous about having dental treatment I have had an upsetting dental experience None of the above apply to me My teeth, or some of my teeth, are sensitive to: * Hot or cold Sweet Biting or chewing None of the above apply to me I understand that I must provide 48 hours of notice for rescheduling or cancelling an appointment or I will be charged a $250 fee. I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all of the questions to the best of my knowledge. I will notify the dentist of any change in my health or medication. Today's Date * MM DD YYYY Thank you! We will be in touch if we have any questions prior to your appointment.However, if you need to speak to our friendly team right away, please call us on (02) 9264 5195. The New Patient Form must be submitted a minimum of 30 (thirty) minutes prior to your scheduled appointment time.Please note, we have a 48-hours Cancellation Policy More from Anokhi Dental:If you’d like to connect with Anokhi Dental, please follow us on Instagram. General Enquiries First Name * Last name * Email * Contact Number * How can we help? * How should we contact you? Please select one or both Email Phone Please confirm: * I have read and agree to the Anokhi Dental Privacy Policy and Terms and Conditions. Yes, I would like to receive information regarding new products, services and content from Anokhi Dental! We’ll be in touchThanks for completing our enquiry form. We’ll be in touch soon. However, if you need to speak to our friendly team right away, please call us on (02) 9264 5195.
