Family Friendly Dental Centre "Great Teeth, Beautiful Smile"

220 Main Road, Tawa, Wellington

04 886 1904

Dental Registration Form

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Dental Registration Form

Name: Centre of Dental Excellence
Address: 220 Main Road, Tawa, Wellington
Telephone: 04 886 1904
Price range: $$

– Register with a dentist taking new patients

If you would like to register at Centre of Dental Excellence, you will need to fill in our dental registration form. You can either fill in the online form below and click send or you can download the PDF, print it out, fill it in and bring it with you to your first appointment. If you prefer, you can fill in the registration form when you come in for your first appointment.

Download dental registration form

The Centre of Dental Excellence, 220 Main Rd, Tawa, Wellington - P: 04 2328001: | M: 0274 545 475 | E: Wellington@dental.net.nz

'The Centre Of Dental Excellence’

Title

Mr.

Mrs.

Miss.

Ms.

Master.

Dr.

First Name

Surname

Date of Birth

Age

Address

City/Town

Phone Contacts Hm

Phone Contacts Wk

Phone Contacts Mob

Email address*

Occupation

If at School, or a Teaching Institution, please name

Referred By

Yellow Pages, Newspaper, Web Site or Other (please mention)

EMERGENCY CONTACT DETAILS

Name of Doctor

Address

Phone

Name Of Nearest Friend Or Relative

Address

City/Town

Phone

DENTAL HISTORY

Name of Last Dentist

Date (Approx) Last Attendant

Is This Is ACC Related?

Any Previous ACC Dental History?

Approx Date

Reason For Attending For This Appointment

Are You In Pain?

Yes

Are Your Teeth Sensitive To Hot, Cold or Sweet Foods?

Do Your Gums Bleed?

Yes

Do You Consider That You Have Bad Breath?

Yes

Is There Any Thing Else We Should Know About Your Teeth Or Oral Health?

PERSONAL MEDICAL HISTORY

DO YOU CONSIDER YOURSELF TO BE IN GOOD HEALTH?

Yes

Do you have an existing illness?

Yes

If Yes, please describe

Have you been hospitalized in the last two years?

Yes

Do you bleed excessively when cut?

Yes

Are you presently taking any medication?

Yes

If so, please list and for what medical condition

DO YOU HAVE A HISTORY OF ANY OF THE FOLLOWING?

Do you have any history of the following

Heart Disease

High Blood Pressure

Rheumatic Fever

Heart Murmur

Prosthetic Devices (eg Hip Joints)

Diabetes

Strokes

Epilepsy

Tumor History

Liver or Kidney Diseases

Hepatitis

Respiratory Ailments (ie Asthma)

Venereal/Sexually Transmitted Diseases

HIV or AIDS

Cold Sores

Are you Pregnant

Yes

if so, how long

Any Known Allergies to

Penicillin

Other Antibiotics

Local Anesthetics

Other

FINANCIAL: * The Practice is a strict payment on the day Practice unless approved by the Dental Practice Principal*

Person Responsible For Paying This Account

Preferred Method Of Payment

Cheque

Cash

Credit Card

Eft-Pos

Auto Payment

Finance Company

Please note, that any costs that may be incurred to recover any debts outstanding may be added to your final dental account. By signing or ticking the terms of conditions, I indicate that I have the understood the above contents and am fully informed as to the contents of this document. Further, I consent to and authorise the Dentists at the CODE Group to, the administration of local anesthesia, take X-rays and other related dental procedures as provided by the Professional and Auxiliary Dental Staff of the Centre of Dental Excellence

Terms*

By ticking the box, I understand I agree to the below terms

Full name

Date

Physical Address
220 Main Road, Tawa,

Wellington

Hours Of Operation

Monday - Thursday: 8:30am - 5.00pm

Friday: By Appointment Only

Contact Number
04 886 1904

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Tawa | Wellington | Porirua

Page: Dentist Taking New Patients Tawa, Newlands, Porirua, Wellington - Last updated: 29th March, 2026

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Family Friendly Dental Centre "Great Teeth, Beautiful Smile"

220 Main Road, Tawa, Wellington