New Patient Form

PATIENT INFORMATION and HEALTH QUESTIONNAIRE

Please take the time to answer the following questions carefully as the information will help us to provide you with high quality dental care. All information given will be treated confidentially.

GENERAL HEALTH INFORMATION

The following information regarding your general health is important because your oral health can be affected by certain medical conditions. Some of the tablets or medications you take may also affect your treatment and may mean that we need to take special precautions for you. Please list all of your present medications (including over the counter treatments such as painkillers, vitamins and natural therapies) and any that you have taken in the last six months.

DENTAL HEALTH INFORMATION

THANK YOU FOR YOUR PATIENCE IN COMPLETING THIS QUESTIONNAIRE

Privacy Policy

Our commitment to privacy
Our practice is committed to safeguarding the personal information of patients and staff in line with our obligations under Commonwealth legislation as well as guidelines set by industry regulatory bodies such as the Australian Dental Board.
What information do we collect about patients and why?
Administrative data
Our practice collects administrative data for accounting purposes, including name, phone number, contact address/billing address, private health care fund and number, Medicare number (if required for government-sponsored programs), financial records of accounts and payments (kept for five years, as required by the Australian Taxation Office) insurance claims records, work related injuries (records kept for five years as required under WHS legislation), complaints.
Who else may see the information?
We may use patient information to discuss treatment with our practitioners. We may use it in a de-identified form for academic purposes, or with insurance officers or lawyers where the treatment relates to an Insurance claim or complaint.
Heath Identifiers
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).
Access and correction
Patients and staff may request access to their information or make changes to their information at any time except where we consider there is a sound reason under the Privacy Act or other legislation. We may charge to recover costs in providing access to electronic or paper records. We aim to use accurate, current and complete information or dispose of any unsolicited information or information no longer required.
How safe is your information?
Our practice takes all reasonable steps to protect your personal information from misuse interference and loses and from unauthorised access, modification or disclosure.