Make an Appointment (Fields marked with a * are required for submission) Your Name* Please let us know your name. Your Email* Please let us know your email address. Date of Birth* Please enter your date of birth Contact number* Please enter a phone number we can contact you on. Alternative contact number Invalid Input Are you a new or existing patient with us?* New PatientExisting Patient Are you a new or existing patient with us? Your Health Fund* Invalid Input Health Fund member number Invalid Input Canberra City Dentistry is open from 8am to 5pm Mon-Fri, with lunch between 1-2pm. We are closed on public holidays. Your preferred appointment date and time Invalid Input We will always try to book you in at your preferred time and date, but if this is not possible what alternative day and time works for you? Alternative appointment date and time Invalid Input Reason for your appointment* Please enter the reason you need an appointment. COVID-19 Risk Assessment Questions Please tick if any of the following that applies to you:* You have returned from overseas or interstate travel in the past 14 daysYou have felt unwell, including but not limited to symptoms of COVID-19 such as fever, sore throat, cough, or shortness of breathYou have had any contact with a confirmed or suspected case of COVID-19 in the past 14 daysYou are currently been quarantinedYou are over the age of 70 years old; or you suffer from chronic disease in particular cardiovascular or respiratory disease; or you are are immunocompromisedNone of these are applicable Please make a selection from the COVID-19 Personal Assessment list Has anyone in your household been affected with any of the above?* YesNo Please indicate whether household members have shown symptoms A member of the team will be in in contact to discuss the arrangements of your appointment. Please be aware the patient should attend alone or with a single accompanying person. Declaration* I agree that the above information supplied above is true and correct Please acknowledge the the information you have supplied is true and correct Antispam* Invalid Input
