New Patient and Medical History Form

Step 1 of 2

New Patient Form

Emergency Contact Information

The fields with * are required

Medical History

For Women:

Privacy Policy and Consent

All personal information collected by Carina Gardens Dental is handled in accordance with our Privacy Policy. We will not share your details without your consent.

By signing this form you hereby agree and acknowledge that: (i) you have accurately completed the patient/medical history to the best of your knowledge; (ii) you consent to any treatment agreed upon, to be carried out by the dentists and their staff; (iii) you are responsible for payment of all services rendered on your behalf and on behalf of your dependents; (iv) payment is due at the time of service unless other arrangements have been made; and (v) your dentists may take images of your teeth both before and after your treatment. These images may be used in a practice portfolio to showcase examples of dental work to other patients (your identity will remain anonymous).

The fields with * are required

Ashley at Carina Gardens Dental

Hi, you’re chatting with Sally. If you could please fill out all your details below, I will be in contact with you shortly.

The fields with * are required

By submitting this form, you agree to be contacted about your enquiry or appointment.

Carina Gardens Dental - Download Price List

Download Free Price List

Please enter your mobile number and email address so we can send you the price list via SMS and email along with some of our patients’ smile transformations in the next few minutes.

The fields with * are required

By submitting this form, you agree to be contacted about your enquiry or appointment.