Patient Forms Pack 2026

5 professionally designed, ready-to-use patient forms for Australian dental practices — 14 pages covering new patient medical history, patient satisfaction survey, healthy smile assessment, emergency triage, and dental records transfer authorisation. Updated April 2026. Simply add your practice logo and name and the forms are ready to use.

✔ Fully editable Microsoft Word format — add your practice logo and name
✔ 14 pages — 5 complete forms
✔ Compliant with the Privacy Act 1988 (Cth)
✔ Includes NPS scoring in the satisfaction survey
✔ Emergency triage form includes a 3-tier pain urgency scale
✔ Instant digital download
✔ Single-practice licence

What's Included — 5 Forms:

Form 1 — Patient Medical History and Consent Form
Comprehensive new patient intake form covering personal details, health fund and billing, referral source, full medical history (30+ conditions with Yes/No tick boxes), current medications, lifestyle (smoking, vaping, alcohol), dental history, a "Your Smile" cosmetic and clinical concerns checklist (18 items), and patient declaration with Privacy Act 1988 acknowledgement. Version 3.0 — April 2026.

Form 2 — Patient Satisfaction Survey
18-statement satisfaction survey rated on a 1–5 scale (Strongly Disagree to Strongly Agree) covering reception experience, wait times, clinical experience, treatment explanation, trust, cleanliness, cost transparency, and rebooking. Includes an overall experience rating (1–10), NPS score (0–10), and open-ended comments section (what we did well, what we could do better, other comments). Includes a Google review prompt at the end.

Form 3 — Healthy Smile Assessment
12-question pre-consultation cosmetic and clinical assessment questionnaire for use before smile consultations. Covers tooth colour and staining, gaps, worn or chipped edges, tooth size, existing dental work appearance, silver fillings, gum health, smile confidence, and grinding/clenching. Each question has a Yes/No tick and a comments column.

Form 4 — Toothache and Emergency Triage Form
Reception-completed emergency triage form with a 3-tier pain urgency scale: Urgent (7–10, same day), Moderate (4–6, 1–2 days), Low (1–3, within 7 days). Captures pain score, location, duration, constant vs intermittent, aggravating and relieving factors, swelling, current medications, relevant medical conditions, appointment offered, and notes.

Form 5 — Authorisation for Transfer of Dental Records and X-Rays
Privacy Act 1988-compliant records transfer authorisation form covering patient details, additional family members, transfer from and to practice details, records to be transferred (full record, X-rays only, clinical notes only, or all), and signed patient authorisation. Includes practice guidance: retain signed form in records transfer register, transfer within 10 working days.