In order to provide you with the highest standard of dental care, this practice is required to collect personal information from you. This information covers basic details such as your name, address and telephone number, but it is also necessary for us to obtain from you details regarding your general health and past medical or surgical treatments and procedures. Without this general health profile, the treating Dentist or Hygienist is unable to plan your care properly.
Naturally, some of this information is of a personal nature, some of it may be regarded as 'sensitive' and not the sort of information you would wish to be unnecessarily disclosed to others. Our practice is equipped with CCTV security cameras always visible and in discreet areas such as the waiting room, treatment rooms and the sterilisation area. Our monitored system is installed to keep the safety of our patients and staff in check when and if required. You can rest assured that our system records and saves video footage only for a few days and records it over itself again. This assists us in ensuring safe delivery of treatment services are being carried out at all times as well as for our staff's safety and peace of mind. If you are concerned in any way, please don't hesitate to contact us. We value the need to safeguard this information and in accordance with the principles laid down in privacy legislation and the guidelines issued by the Australian Dental Association, we would like to assure you that:
• This information will only be used by the treating Dentist or Hygienist in order to deliver your care to the highest standards.
• It will not be disclosed to those not associated with your treatment without your expressed consent.
• You may seek access to the information held about you and we provide this access within 2-3 days of a written request received. This access might be by inspection of your dental records at the time of your appointment or by special access or copying of information at other times by completing a records release request form.
• We will not send clinical information about patients via email unless it is to secure domain email addresses and not gmail, yahoo, hotmail or other free emails.
• We will take reasonable steps to ensure at all times that the details we keep about you are accurate, complete and up-to-date.
• We will take all reasonable steps to protect the privacy of our patients’ information from misuse or loss and from unauthorised access, modification or disclosure.
• Our staff are trained to respect these principles at all times.
If you have any questions regarding the information we collect from you and hold in your dental records, please do not hesitate to ask us. We are acting in your interest at all times.
I agree to the privacy policy.
Yes, I'm an existing patientNo, Im a New Patient
Dr.Mr.Mrs.Miss.Ms.Mx.Prefix
First Name
Last Name
Street Address
Suburb
Postcode
Phone *
Work Phone
Email *
Date of Birth *
Occupation
Emergency contact name*
Relation to you *
Emergency contact phone *
To protect your privacy do you give consent for a third party or family member access to your records? YesNo If yes, please provide details below.
Full name of third party or family member
Relationship
Contact details
Health Insurer
Ref. No.
Member No.
Who referred you to our practice?
When was your last dental visit?
Why did you leave your last dentist?
What has been your concern with previous dental visits?
What is your main dental concern today?
Are your teeth sensitive to: HotBiting pressureColdSweet
Does food catch between your teeth? YesNoSometimes
Do your gums bleed when brushing or flossing? YesNoSometimes
Do you notice an unpleasant taste or odour in your mouth? YesNoSometimes
Have you had any complications during or after dental treatment? YesNo Details if Yes
Have you had prolonged bleeding after tooth removal or dental surgery? YesNo
Is there anything you would like to change about your teeth/gums or their appearance?
Do you grind your teeth or clench your jaws?* YesNoSometimes
Do you suffer from: Sore jaw musclesHeadaches / MigrainesNeck / Backpain
Do you feel sleepy or tired during the day? YesNoSometimes (during some activities)
Please describe how you feel about dental treatment (1: Pleasant to 10:Terrible) 12345678910
Do you smoke? NoVapeCigarettesOther
If Yes, how many/often per day
Have you recently quit smoking? YesNo
If Yes, how long ago?
If Yes, how many/often per day?
What is your current body weight (kg)?
Average alcohol units consumed per week
Are you pregnant? YesNo1st Trimester2nd Trimester3rd Trimester
If Yes, when is your due date?
Are you breast feeding? YesNo
Are you taking contraceptives? YesNo
If Yes, please name contraceptive
Are you being treated for a medical condition? YesNo
Details if Yes
Who are your doctors/GP/GP Clinic/Specialist? We may request access to medical history or medications for some dental treatments.
Phone
Do you take any of the following medications, supplements or treatments? Chemo / Radiation TherapyHerbal / Natural MedsAnxiety MedicationsAnti-depressantsBlood ThinnersProlia InjectionThyroxinAsthma InhalersCholesterol MedsBisphosphatesBlood Thinners – Warfarin or AspirinSteroid Tablets
Please list names of all medications or supplements including those not listed above with dosage and frequency:
Do you have any allergies or sensitivity to any of the following? AntibioticsLactose / Milk productsCodeinePenicillinLatexBandagesVarious FoodsSulphur Drugs
Please list all allergies including those not listed above and describe the reactions:
I DECLARE I HAVE NO KNOWN ALLERGIES
Do you have, or have you ever had, any of the following medical conditions?
Steroid therapyEpilepsyDiabetes Type 1Diabetes GestationalStrokeKidney problemsEating disorderLeukemia, cancersTuberculosisHigh blood pressureOrgan or bone marrow transplantBleeding problemsHIV/AIDSProsthetic implant eg. Prosthetic hip or kneeLung diseaseThyroid diseaseHyperthyroidism
Rheumatic feverAsthmaDiabetes Type 2Heart valve disorderRadiation or chemotherapyHeart complaint or heart surgeryStomach or digestive condition (reflux)Nervous conditionHeart murmurLow blood pressurePacemakerHepatitis or liver diseaseAnemia or blood disorderBronchitis, emphysema or otherOsteoporosisHypothyroidism
Other
I DECLARE I HAVE NO MEDICAL CONDITIONS
We like to see you smile with confidence and get the most out of your visits. Please tick the dental care options you'd like to know more about or would consider in the future:
Gum Therapy / Rejuvenation (PST)Fresher BreathDry MouthTeeth WhiteningOral Health Tips
Tooth Coloured FillingsChildren's DentistryCosmetic Tooth AlignmentMissing Teeth Options
Dental Excellence from time to time offers in-house specials, gift vouchers, products, promotions and information seminars.
Would you be interested in receiving information?
YesNo
Would you like to receive special offers via SMSEmail
To the best of my knowledge, the questions above have been accurately answered. I understand the importance of providing both accurate and updated information to Dental Excellence. I Agree
I understand 24 hours notice is required for cancellations or changes to my appointment, as fees may apply. I Agree
I Consent
I Agree *
Name *
Date *
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