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HOW CAN WE HELP?

Please fill in the form to let us know how we can be of assistance. A member of our team will get back to you as soon as possible.

If you wish to make a booking, please give us as much detail about times and days that best suit you.

If you have an emergency please call on the number below. We keep an allocation of time reserved for urgent appointments every day.

Bay Dental Care, 507 St Aubyn St West, Hastings
info@baydentalcare.nz
manager@baydentalcare.nz
06 878 8791

Dentist Reception at Bay Dental Care Hastings

Name*
Surname*
Email*
Best Contact Number*
I wish to:*
- Make a General Enquiry
- Book an Appointment
Are you an existing client of Bay Dental Care?
- Yes
- No
Your Message
What is your date of birth?*
Title
Address*
Address line 2
Moblie Phone*
Home Phone
Work Phone
Emergency Contact: Name*
Emergency Contact: Relationship*
Emergency Contact: Phone*
Dental / Medical Insurance
Medical History
Please select as appropriate
- Heart Problems / Surgery
- Smoker
- Blood Pressure
- Asthma / Lung Problems
- Rheumatic Fever
- Diabetes
- Blood / Bleeding Disorders
- Joint Replacement
- Osteoporosis / Bone Problems
- Stroke
- Have you ever taken Fosamax or another bone medication
- Epilepsy
- Radio / Chemotherapy
- Organ Transplant
- Hepatitis / Liver Disease
- Pregnant
- HIV
Do you have any allergies?
Do you have any current medical issues?
GP's Name*
GP's Practice*
Which day of the week do you prefer?
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Do you prefer morning or afternoon?
- Morning
- Afternoon
What is the reason for your appointment?
Injury Declaration*
Although rare, accidental injury to your dentist and staff can occur from the handling of sharp instruments. If this happens during the course of your treatment, our practice requires both the patient and staff member to undertake a blood test. Do you agree to a confidential blood test if required?
- Yes
Missed Appointments*
I understand that payment is required at the time of treatment / consultation. Missed appointments, late attendance or cancellation with less than 4 hours notice will incur a fee of $85 per 30 minutes of scheduled time. Do you agree to these terms?
- Yes
As a health service provider, Bay Dental Care is obligated to treat you in a manner compliant with the Health & Disability Commissioner’s Code of Rights. These can be made available to you upon request.
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Dentist Reception at Bay Dental Care Hastings

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