Online Form

Our comfortable waiting room area

Use the form on this page to help us make an appointment for you

Personal Registration Form
  1. The information entered in this form is Strictly Confidential and will never be given to anyone outside of Henderson Periodontics and Implants
  2. Salutation

  4. (required)
  5. (required)
  7. (required)
  8. Gender
Contact Details
  1. (required)
  5. Preferred Contact
  7. (valid email required)
Your Professionals Details
Emergency Contact Details
Your Medical History
  1. Are you at present having any medical treatment
  3. Have you ever had a serious illness
  5. Have you ever been in hospital as a patient
  7. Have you had any joints replaced
  9. Have you ever had a heart condition or high blood pressure
  11. Are you taking any medicine tablets or drugs including herbals
  13. Do you smoke cigarettes
  15. Have you any known allergies or had any reaction to medicines
  17. Have you ever had any treatment for excessive bleeding
  19. Have you ever had contact with HIV
  21. If female are you pregnant
  24. Have you ever had

Where did you hear about us
Acknowledgement
  1. Having completed this form, being the patient, parent or guardian of the above minor patient, believe that the above information is correct to the best of my knowledge and agree to advise any changes to my health in the future.
  2. Please note a fee of $50 for each half-hour appointment may be charged if you fail to attend your scheduled appointment or if you cancel your appointment within 24 hours.
Confirmation
 

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Save time when you arrive

Complete our form online and then when you arrive for your appointment all the hard work has been done, by you!

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