(08) 8995 9530

Contact Us

Name*
Prefix First Last
Email*
Phone*
Preferred contact method*
- Mobile
- Email
What type of appointment do you require?*
Please Select*
- I'm a new patient
- I'm an existing patient
When did you last visit the dentist?
Have previous x-rays been taken of your teeth?
- Yes, less than a year ago
- Yes, but taken over a year ago
- No
Please describe how we can help you?
Are you in any pain?
Please check all that apply
- Pain triggered by heat
- Pain triggered by cold
- Painful to sweet foods
- Painful to chew on
- Pain comes without any warning
- Headaches
- Throbbing ache
- Dull ache
- Sharp shooting pain
- Waking up at night
- Constant pain
- Pain comes and goes
- Pain lasts only for a few seconds
- Pain lingers for a few minutes
- Pain can last for a few hours
- Radiating pain to ears, temple, jaws etc
- Other
Details
Which tooth/teeth is causing you the problem?
Have you had an OPG x-ray taken of your teeth?
An OPG is a scanning x-ray taken of your entire jaws to help identify the position of wisdom teeth and also any other problems in your jaws and jaw joints.
- Yes
- No
Preferred Date of Appointment
DD slash MM slash YYYY
Do you require an after-hours appointment?
Please note we may request a deposit from you to secure an appointment after-hours. This helps to cover staff costs in cases of no-shows or late notice cancellations of less than 24 hours.
- Yes
- No
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