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New Patient Form

The array of services available at Broadway Dental Centre in Palmerston North includes preventative, general and cosmetic dentistry.

New Patient Form

Welcome to our practice! We look forward to giving you the best service possible so that you can enjoy the benefits of optimal dental health.

Patient Details

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Emergency Contact

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Medical History

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Allergies

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General Release: I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorise the dentist to perform diagnostic procedures as may be required to determine necessary dental treatment. I understand that information provided from or to my medical doctor or another HealthCare provider may be necessary and I consent to the release of this information. I understand that responsibility for payment of dental services for my dependants and myself are mine, and I assume responsibility for fees associated with these services. I am aware of and understand that payment is required at the end of each appointment, and that if an account is sent to me, I will incur a $10 management fee. I am aware that if I fail to attend an appointment, there will be a $50 per half hour failure fee or if my account is sent to a Debt Collection agency, I will incur a 25% additional fee of the amount owed.

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