New Patients

Your Details

If under 18 years of age, enter person responsible for account

Your Health History

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.

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.