Useful Information

Opening Hours

Opening Hours

Mon: 7:30am - 5:30pm
Tue: 7:30am - 5:30pm
Wed: 7:30am - 7pm
Thu: 7:30am - 5:30pm
Fri: 7:30am - 4:30pm
Sat (every 2nd):
7:30am - 1pm


Our Location

Our Location

Click here to find us on google maps


Contact us

Online Patient Forms

Click here to complete
our patient form before
your first appointment


Share Your Story

Visit our page and tell us about your experience at Kelmscott Dental

Read & Write Reviews

Patient Form

At Kelsmcott Dental we strive to provide you with the highest possible care. To do this we need to collect personal information from you that include contact details and matters pertaining to your general health, both past and present. Without this information it is difficult for your dentist or hygienist to plan your care properly.

Please be assured that this information is maintained in accordance with State and Federal Privacy Legislation. If you would like any further information about how we use and protect your personal information, please ask one of our staff for our “Personal Information, Privacy and your Dentist” document. Click here for our privacy policy.

Click here to download the pdf version.

Patient Information
Date of Birth:* Title:
Given Name:* Middle: Surname:*
Address:*
Suburb:* Postcode:*
Ph (home):* Mobile Number: Ph (work):
E-mail:* Drivers License No:
Private Health Fund: Number: Position on Card:
Department of Veterans Affairs:
(If under 18) Guardian Name: (Phone):
Occupation: Employer Name:
Contact Information
How would you like to receive appointment confirmations:
Would you like to join our Free Dental Insurance Program? (Dentisure)
Who may we thank for referring you to our practice?
Name of your Friend or Family member ($50 voucher will be sent):
Other:
Medical/Dental History
When did you last visit a dentist?:
When did you last have oral x-rays:

How often do you:

Brush your teeth
Floss
Rinse with mouth wash

Please Tick any of the following if they apply to you:

If pregnant, how many months are you?:

Number of standard drinks (if any) consumed per week:

Wine: Spirits:
Beer:
If you have checked any of the boxes above, please provide details::
Do you suffer any allergies?:*
If yes, please state:
Are you currently taking medication?

If yes, please state

Drug, Strength and Frequency:
How did you hear about us?
Referral Source:    
Keep Informed Yes No
To receive updates and be kept informed on what is new in the practice, services and new dental techniques that may affect my next visit.
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Consent for Services

I have accurately completed this pre-clinical questionnaire to the best of my knowledge.I hereby give my authority for any treatment agreed up on by me, to be carried out by the dentists and their staff and I assume full financial responsibility for said treatment.