InstagramThis field is for validation purposes and should be left unchanged.New Patient Registration Form (Patient Information and Medical History) Please complete this form prior to your appointment. If you don't have the name of your Dentist or GP, please disregard. Please ensure that all required fields are completed and that you are redirected to the "thank you" page before exiting. Otherwise, we may not receive your submission. Personal InformationTitle* Master Mr Miss Ms Mrs Dr Other (please specify) Other (please specify)*Given Name*Surname*Preferred Name*Date of birth* Gender* Female Male Other Email* Pronouns*Home address* Address Line 2 Suburb State Postcode Phone (home)Phone (mobile)*Phone (work)OccupationEmergency ContactEmergency contact full name*Relationship*Contact number/s*Health Fund (We are unable to process any health insurance claims (HICAPS) Do you have private health insurance (Hospital cover)?* Yes No Do you have extras (Dental cover)?* Yes No Provider NameMember NumberPosition Number on CardMedicare Information Do you have Medicare?* Yes No Medicare NumberPosition NumberExpiryPerson Responsible for Fees (if under the age of 18) First Last Date of Birth Medicare NumberPosition NumberExpiryReferral (How did you hear about us / who referred you here?)* General dentist Dental specialist Medical doctor Current or former patient Family member / friend Word of mouth Google Signage Other (please specify): If applicable, please provide nameGeneral Dentist InformationClinician NameClinic NameContact NumberSuburbMedical Doctor InformationDoctor NameClinic NameContact NumberSuburbMedical Information Do you have or have you ever suffered from any of the following? Please indicate: If you are unsure about anything please discuss with your surgeon.Any heart complaints / condition / murmur / pacemaker* Yes No Any joint problems / arthritis / history of joint replacement surgery* Yes No Blood pressure: high / low* Yes No Tuberculosis* Yes No Diabetes: type I / type II* Yes No Thyroid problems* Yes No Radiation therapy / chemotherapy* Yes No Kidney problem* Yes No Rheumatic fever* Yes No Asthma / bronchitis / lung conditions* Yes No HIV / AIDS* Yes No Anxiety / depression / other* Yes No Osteoporosis / bisphosphonate therapy* Yes No Are you a blood donor?* Yes No Are you currently taking any medications or tablets regularly?* Yes No Stroke / seizures / epilepsy / other neurological problems* Yes No If YES, please specify medication name, dosage and frequencyDo you smoke or have you ever been a smoker?* Yes No If YES, how many per day, and for how longHave you ever stayed in hospital, had an operation or a general anaesthetic?* Yes No If YES, please specifyLiver problems / hepatitis* Yes No If YES, please specifyBlood disorder / excessive bleeding* Yes No If YES, please specifyFor women only: Are you pregnant* Yes No If YES, when are you due*Do you have any allergies or had a reaction to medications or latex?* Yes No If YES, please specify*Have you ever had any serious problems after dental treatment?* Yes No If YES, please specify*Any other medical conditions?* Yes No If YES, please specify:*Privacy Policy and Important Information We respect your right to privacy and we have systems in place to ensure we comply with the Australian Privacy Principles. Our practice collects health information about you in order to provide you with dental services. Personal information collected such as your name, address, contact details, health insurance and financial details are used to address accounts to you, process payments, collect unpaid invoices via an external collection agency, and to contact you about our services and any issues affecting your health. We may collect your health information from other health professionals, or disclose information to them if, in our judgement, it is necessary in the context of your care. If you choose not to provide us with information relevant to your care, we may not be able to provide a service to you, or the service we are asked to provide may not be appropriate to your needs. Importantly, you could suffer some harm or other adverse outcome if you do not provide us with relevant information. We will securely store your records, such as x-rays, treatment and personal details and any other material relevant to your care. For administration purposes, we may rely on service providers located outside Australia. We will take reasonable steps to ensure that any offshore data transfer complies with Australian privacy laws. Whilst our practice takes all reasonable steps to ensure security of your information, we cannot guarantee secure transmission of information over the internet. We may use parts of your health information for teaching and research purposes. All information collected and used will be de-identified. Please let your clinician know if you do not wish for your case to be used for research or teaching purposes. Please note that accounts are payable on the day. An administration fee will apply for unpaid accounts that have not been settled within 14 days from the time of treatment. Consent for Services We respect your right to privacy and we have systems in place to ensure we comply with the Australian Privacy Principles. Our practice collects health information about you in order to provide you with dental services. Personal information collected such as your name, address, contact details, health insurance and financial details are used to address accounts to you, process payments, collect unpaid invoices via an external collection agency, and to contact you about our services and any issues affecting your health. I agree that the information provided on this form is a true and accurate record I understand that Western Dental Specialist Group requires full payment on the day of treatment I understand I may be charged an $50 fee if I cancel my appointment with less than 24 hours notice. In addition, repeated non-attendance may result in a fee or deposit being paid prior to future appointments being scheduled. By signing this form, you agree to our privacy policy. Furthermore, you agree that the personal and health information you have provided herein is true and correct, to the best of your knowledge, and you understand that any failure to disclose information may be detrimental to your treatment. In the event where your overdue account is referred to a collection agency and/or law firm, you will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs.Patient/Guardian Name* First Last Signature*Date* Please ensure that all required fields are completed and that you are redirected to the "thank you" page before exiting. Otherwise, we may not receive your submission.
