Patient Form

Please take a moment to complete the patient form below. If you have any questions or require assistance, you can call us at 0800 255 764. For a downloadable copy, click here.

Name(Required)
DD slash MM slash YYYY
Address(Required)


Medical


HEART (Have you ever had or do you have)


CHEST (Have you ever had or do you have)


SMOKING HISTORY (Are you a smoker or have you previously smoked?)


BLOOD (Have you ever had or had contact with)


OTHER (Have you ever had or do you have)


ALLERGIES (Are you allergic to, do you have or have you had a reaction to)


EXTRA CAUTIONS


What is your estimate of your general health?


Are you receiving any medical treatment or medication at the present time?


Have you been a patient in hospital during the past two years?




Do you have Dental pain or Dental problem at present?


Do you become anxious or uncomfortable when having dental treatment?


Are you currently or have you ever used Botox or dermal fillers?


Patient Consent(Required)
DD slash MM slash YYYY


This field is for validation purposes and should be left unchanged.
Orthodontics
Restorative
Advanced Services

Contact Us

All Smiles Dental

395 Dominion Road
Mount Eden
Auckland 1024

Phone  0800 255 764
Email  info@allsmiles.co.nz

Hours

Monday 9:00AM – 8:00PM
Tuesday 9:00AM – 8:00PM
Wednesday 8:00AM – 4:00PM
Thursday 8:00AM – 8:00PM
Friday 8:00AM – 3:00PM
Maps were disabled by the visitor on this site. Click to open the map in a new window.

Find available appointments

Book Online

Quick Links

About Us
Our Technology
Reviews
Patient Form
Policies

Orthodontics

Invisalign
Fastbraces
Myobrace
Growth Guidance Orthodontics
Conventional Braces
ClearCorrect Aligner
Inman Aligner

Restorative

General and Cosmetic
Bridges
Componeers
Crowns
Veneers
Dental Implants
Dentures
Fillings and Amalgam Remover

Advanced Services

Sedation
Hygiene Services
Oral Surgery & Wisdom Teeth
Root Canal Treatment

Contact Us

All Smiles Dental

395 Dominion Road
Mount Eden
Auckland 1024

Phone  0800 255 764
info@allsmiles.co.nz