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TEL: 035821 6997

Knight Street Dentists

Confidential Patient Information

Welcome to
Knight Street Dentists

Thank you for placing your dental care in our hands. We will do our utmost to respond to your needs. We have a commitment to provide comprehensive dentistry that is suited to you. It is our belief that you deserve nothing less than the best service modern dental care can offer.

Name*
Home address*
Date of birth*
MM slash DD slash YYYY
Postcode*
Phone*
Mobile*
Business*
Email Address*
Payor*
Emergency contact*
Emergency contact phone*
Medical doctor*
Payment is required on the day of service. Preferred Payment option:*
- Cash
- Cheque
- EFTPOS
Do you have dental insurance?*
- Yes
- No
If yes, which fund:
When was your last Dental Examination?
Previous Dentist :
Who recommended this practice to you?
Are you happy with the appearance of your teeth?*
- Yes
- No
Have you ever had any of the following:
Rheumatic fever*
- Yes
- No
Epilepsy*
- Yes
- No
Asthma*
- Yes
- No
Tuberculosis*
- Yes
- No
Diabetes*
- Yes
- No
Rheumatic fever*
- Yes
- No
Liver or kidney disease*
- Yes
- No
Jaundice/hepatitis*
- Yes
- No
Heart ailment*
- Yes
- No
AIDS/HIV*
- Yes
- No
Excessive bleeding*
- Yes
- No
Joint replacement*
- Yes
- No
Would like to discuss any of these questions in private with the dentist?*
- Yes
- No
Female patients, are you pregnant?*
- Yes
- No
If yes, how many weeks?
Do you smoke?*
- Yes
- No
Do you have any allergies?*
- Yes
- No
If yes, please list :
Are you, or have you at any time, been treated for osteoporosis, bone cancer or any bone conditions?*
- Yes
- No
Current medications, herbal or otherwise ;
Consent*
I verify that all details I have provided in the medical history form is true and accurate. I understand that interest on overdue invoices shall accrue daily from the date of unpaid treatment to the date of payment at a rate of three per cent (3.0%)per calendar month. I indemnify Knight Street Dentists from and against all costs and disbursement incurred in recovering overdue invoices (including but not limited to legal costs, collection agency costs, internal administration costs and bank dishonour fees).*
Email
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Let’s book you in and get you smiling again

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[email protected]

79 Knight St
Shepparton VIC 3630

Monday – Friday
8:45 AM – 5:45 PM

[email protected]

79 Knight St
Shepparton VIC 3630

Monday – Friday
8:45 AM – 5:45 PM

At Knight Street Dentists, our modern, progressive and friendly approach to dentistry make your visits more pleasant. We are committed to providing comprehensive, high quality dental care and service.

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Booking Fee Policy

Cancellation Policy

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03 5821 6997 New Patients

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Booking Fee Policy

Cancellation Policy

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Dental treatments that will turn your frown upside down

Shepparton

Shepparton

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Treatments

Dental treatments that will turn your frown upside down

Dental Checkup & Examinations
Conscious Sedation
Wisdom Teeth
Extractions
Root Canal Treatment
Bruxism
Invisalign Treatment
Teeth Whitening

Dental Checkup & Examinations
Conscious Sedation
Wisdom Teeth
Extractions
Root Canal Treatment
Bruxism
Invisalign Treatment
Teeth Whitening

Periodontal Disease
Children’s Dentistry
Mouthguards
Orthodontics
Braces
Cosmetic Dentistry
Restorative Dentistry
Preventive Dentistry
General Dentistry

Periodontal Disease
Children’s Dentistry
Mouthguards
Orthodontics
Braces
Cosmetic Dentistry
Restorative Dentistry
Preventive Dentistry
General Dentistry

Request an Appointment

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