Patient History

Your Details

Title:

Last Name:*

First Name:*

Sex

Date Of Birth:

Email:*

Contact No:

Home:*

Work:

Mobile:

Street Address:*

Suburb:*

State:*

Postal Code:*

Emergency Contact:

Relationship:

Emergency Contact Number:

Medical Doctor:

Medical Doctor Contact Number:

Name of Referring Dentist:

Dental Benefit Fund:

Person Responsible for Fees:

Our Practice Policy is that full payment is required on the day of service.

NOTICE TO INSURED PATIENTS REGARDING DENTAL BENEFITS INSURANCE

Item numbers on our statement represent as accurately as possible the procedures performed, but in no way are they a claim on anyone other than the patient for whom they were performed. The eligibility of the patient or the procedures, to attract refunds, and the rates of those refunds, are determined by the conditions of the patient's health insurance policy. We accept no responsibility to either party, for any decision the insurer may make regarding the refund of monies to the patient.

I have completed this questionnaire to the best of my knowledge, and understand that failure to make a full disclosure may place ME at undue medical risk. I understand that notes, radiographs (x-rays), or models relating to my treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this.

Your privacy is important to us, all information submitted through this form is kept confidential. You may find a copy of our Privacy Policy here.

Patient History

Your Details

Contact No:

Have you ever had any of the following?

NOTICE TO INSURED PATIENTS REGARDING DENTAL BENEFITS INSURANCE