PATIENT DETAILS

First Name (Patient) *

Last Name (Patient) *

Preferred Name

Date of Birth *

Gender

MaleFemaleOther

Address

City / Suburb

State/Postcode

PARENT/GUARDIAN CONTACT DETAILS 1

Name

Relationship to patient

Mobile Phone *

Email

Occupation

PARENT/GUARIDAN CONTACT DETAILS 2

Name

Relationship to patient

Mobile Phone

Email

Occupation

WHO WILL BE RESPONSIBLE FOR THE ACCOUNT (PRIVATE FEES APPLY)

Name *

MEDICARE (all medicare fees are paid up front and in full at each visit)

Medicare First Name

Medicare Surname

Medicare Card No.

Medicare Card ref no.

What number are you (parent/guardian) on Medicare Card

PRIVATE HEALTH INSURANCE

Do you have private health insurance *

YesNo

Do you have Hospital and/or Extras Cover

Hospital CoverExtras Cover

Health Fund

Membership No.

Ref No.

EMERGENCY CONTACT DETAILS if parent is unable to be contacted

Name

Relationship to patient

Mobile Phone

REFERRAL DETAILS

Referral

Referring Doctor (please state below)

Referring Doctor’s Name (if applicable)

Referring Doctors Clinic

FriendWebsiteGoogleOther

MEDICAL HISTORY

Please provide details if necessary

Does your child have any Allergies *

YesNo

If yes, please provide details below

Is your child taking any medication? *

YesNo

If yes, please provide details below

Has your child had any recent medical operations *

YesNo

Has your child had a tonsillectomy or removal or adenoids? *

YesNo

If yes, please provide details

Is your child growing *

RapidlyModeratelyStopped Growing

DENTAL HISTORY

Has your child been in an accident involving their teeth? *

YesNo

If Yes, please provide details below

Is there a family history of any gum disease, missing teeth or any other dental issues? *

YesNo

If Yes, please provide details below

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Because my child is a minor, I give consent for his/her examination and treatment. *

I understand that I am responsible for any financial obligations incurred for my child's treatment and also for incidental costs, and or legal fees necessary to recover the same. *

I am aware that payment is required at the time of each appointment. *

I am aware that two working days notice is required for any cancellations or a $50 fee applies to late cancellations or missed appointments *

I am aware that if I am 10minutes or more late for an appointment that it may be cancelled. *

Patient/ Guardian Signature *

Clear

Today's Date

Print name *

Disclaimer, Your Health Information and Our Privacy Policy

Our practice respects your right to elect which practitioner you wish for your child to see. Please ensure that you are aware of which dentist you are seeing at each appointment and don’t hesitate to ask any of our friendly staff if you have any queries.

Our practice also respects your right to privacy. We realise that it is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our practice and to whom this information might be disclosed.

The policy of our practice is to follow these procedures:

The information collected will be used for the purpose of providing treatment to you. Personal information such as your name, address and health insurance details will be used for the purpose of addressing accounts to you, as well as processing payments and writing to you about our services and any issues affecting your treatment.

We may disclose your health information to other health care professionals, including specialists we may refer you to, or require it from them if, in our judgement, that it is necessary in the context of your treatment. In that event, disclosure of your personal details will be minimised wherever possible.

We may also use parts of your health information for research purposes, in study groups or at seminars, as this may provide benefit to other patients. Should that happen, your personal identity will not be disclosed without your consent to do so. We may use your information with insurance officers or lawyers where the treatment relates to an Insurance claim or complaint.

Your medical history, treatment records, x-rays and other material relevant to your treatment will be kept here. You may inspect or request copies of our records of your treatment at any time, or seek an explanation from the dentist. Statutory fees will apply in relation to the types of access you seek. We may obtain this information from other practitioners with your consent as part of this ongoing care.

If any of the information we have about you is inaccurate, you may ask us to alter our records accordingly.

You can otherwise rest assured that your health information will be treated with the utmost confidentiality. Disclosure will not be made to any person not involved in either your treatment or the administration of this practice, without your prior written consent. The practice will not adopt, use or disclose an identifier assigned by any government agency except health care identifiers for purposes permitted under the Healthcare Identifiers Act (2010)(Cwth). If you have any queries or concerns about our handling of your health information, please do not hesitate to raise these concerns with our practice.

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