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New Patients

We're delighted to have you join our dental family. To ensure a smooth first visit, please fill out our digital form or download and complete the form to bring with you to your appointment. We look forward to meeting you!

Do you Identify as Aboriginal or Torres Strait Islander
Yes
No
Birthday
Day
Month
Year
Your preferred contact method

Do you have dental health insurance?

Do you have dental health insurance? YES/NO
Yes
No

Are you covered by Veteran Affairs?

Single choice
Yes
No
How did you hear about us?

Contact in the event of an emergency:

Once an appointment is booked with us, we will consider this confirmed and will make a courtesy reminder via your preferred method, as nominated above. Please note, failure to attend or should 24 hours’ notice of cancellation not be given, a fee will be charged. Without notice of cancellation we are unable to see another patient in need of our help. We appreciate your understanding in this regard.

MEDICAL HISTORY

Are you allergic to any of the following?
Have you ever had Botox or dermal filler before
Yes
No
Are you taking bisphosphonate medication or any other medication to treat osteoporosis?
Yes
No
Do you have , or have ever had , any of the following medical conditions ? (Please tick if yes)
Are you a smoker?
Yes
No
Are you pregnant?
Yes
No

DENTAL HISTORY

How do you feel about dental treatment?
Have you ever had orthodontic work
Yes
No
Have you ever had difficulty with dental anaesthetic ?
Yes
No
Have you had any oral surgery, eg. wisdom tooth removal?
Yes
No
Have you had any complications during or after dental treatment?
Yes
No
Have you bleached / whitened your teeth?
Yes
No
Have you had prolonged bleeding or infection after having a tooth removed ?
Yes
No
Are you happy with the appearance of your teeth?
Yes
No
Are your teeth sensitive to:
Do you floss?
Yes
No
Do your gums bleed when you brush and /or floss?
Yes
No
Does food catch in between your teeth?
Yes
No
Do you grind your teeth or clench your jaws?
Yes
No
Have you worn a bite appliance / nightguard/ splint / snoring device ?
Yes
No
Have you been diagnosed with TMD?
Yes
No
Have you been diagnosed with gum / periodontal disease?
Yes
No

I have completed this questionnaire to the best of my knowledge, understanding that failure to make a full disclosure may place

me at undue medical risk. I understand that notes, radiographs and models relating to my treatment may need to be sent to

other dental practitioners to aid them in my treatment and consent to this. I also give permission for the practice to use the

above contact details to send me appointment and check-up reminders.

NOTICE FOR PATIENT INFORMATION


Our practice respects your right to privacy and it has systems and processes in place to ensure it complies with the Australian Privacy Principles. This statement is a brief summary of the practice’s privacy policy. The complete policy is available on request.

Our practice trading as Hampton Dental Centre collects information about you for the purpose of providing health services to you. In addition, personal information such as your name, address and health insurance details are 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 health care. We may collect information about you from third parties providing the collection of that information is necessary to provide you with health care.

We may disclose your health information to other health care professionals, or require it from them if, in our judgement, it is necessary in the context of your care.

We may also use parts of your health information for research purposes, in study groups or at seminars; however, in such situations, your personal identity will not be disclosed without your consent.

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 for your needs. Importantly, if you do not provide information that may be relevant to your care or that is otherwise requested by us, you could suffer some harm or other adverse outcome.

Your medical history, treatment records, x-rays and any other material relevant to your care will be stored by the practice. The practice privacy policy sets out how you can access your records or seek correction of your records.

The practice privacy policy sets out how you may complain about a breach of privacy and how the practice will deal with such a complaint.

As part of its electronic records system, the practice may rely on cloud storage providers located outside Australia. The practice will ensure that any offshore transfer complies with its obligations under Australian privacy laws.

The practice Privacy Officer can be contacted at the practice during business hours if you have any concerns or questions about a privacy matter.


Do you give consent for messages to be left with family members or on an answering machine regarding treatment or appointments? Please circle YES NO
Yes
No
Date
Day
Month
Year
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