Your Contact DetailsPrefixMr.Mrs.Ms.Mx.MissDr.Prof.First Name *Middle NameLast Name *Preferred Name *Date of Birth *If under 18 years of age, enter person responsible for accountName *Phone *Relationship *Email Address *Phone (mobile) *Phone (home)Phone (work)Street Address *Apartment, suite, etcSuburb *Post Code *OccupationEmergency ContactName *Phone *Private Health Insurance Provider *General PractitionerName *Phone *How long ago did you visit the dentist? *Select one optionWithin the past monthWithin the past 6 monthsWithin the past yearMore than a year agoHow did you hear about us? *Family/friend/word of mouthGoogle searchSocial mediaAdvertisementSign from the roadOtherYour Health HistoryDo you smoke? *YesNoPlease give further details *Are you allergic to antibiotics (e.g. Penicillin)? *YesNoPlease give further details *Are you allergic to Latex? *YesNoPlease give further details *Have you had any serious health problems/surgeries in the past year? *YesNoPlease give further details *Are you pregnant or breast feeding? *YesNoPlease give further details *Are you significantly anxious about dental treatment? *Not verySlightlyFairlyExtremelyPlease give further details *Do you suffer from any of the following? *Please tick the box for all that applyHigh Blood PressureLow Blood PressureAsthmaArthritisBleeding DisorderDiabetesOsteoporosisContact with HIV/AIDSRheumatic FeverTuberculosisAlzheimer’s Disease/DementiaStrokeHeart Attack/SurgeryHeart ValvePacemakerHip replacementKnee replacementCancerEpilepsyAnaemiaKidney DiseaseHepatitis A, B or CNonePlease give further details *List current medications, illnesses or allergies (including food intolerances) *Consent for Treatment I hereby authorise the dentist or designated team to take x-rays, photography, and diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anaesthetics’, sedatives and other medication as necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand I can ask for a complete recital of any possible complications. I agree to be responsible for payment for all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made. All accounts not paid within our agreed payment terms and are referred to our collection agency will be liable for all fees and costs and any legal fees included to collect the debt outstanding. I authorise that this data may be reviewed by team members of the dental practice. Consent *I acknowledge and agree to the Consent for Treatment.Authorisation *I authorise that this data may be reviewed by team members of the dental practice.Cancellation Policy We realise your time is valuable, as is ours. That’s why we offer an Appointment Reminder Service. If you’re unable to attend your appointment we require you to give us at least 48 hours notice, to allow other patients the chance to book in for the treatment they need. In the event that you cancel within 24 hours or fail to attend this appointment, we may charge a fee. Cancellation Acknowledgement *I acknowledge and agree to abide by the Cancellation Policy.SubmitSave as Draft
