Thank you for taking the time to help us help you. The following information will help you receive our best attention and care. The information you provide will be handled in accordance with our Privacy Policy. First Name*Last Name*Name Prefix*Preferred NameOccupationDate of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Mobile Number*Home NumberEmail Address* AddressStreet*Suburb*State*QueenslandNew South WalesAustralian Capital TerritoryNorthern TerritorySouth AustraliaTasmaniaVictoriaWestern AustraliaPostcode*Emergency Contact DetailsFull NamePrimary Phone Number I authorise Define Dental to provide details about my dental appointments to my emergency contact. I authorise Define Dental to provide details about my dental appointments to my emergency contact.Patient InformationDo you have private health insurance?Do you have private health insurance?NoYesFund NameHow did you hear about us?How did you hear about us?Referred by a friendGoogleWebsiteFacebookInstagramSignageOtherWhich Magazine?Can we please have the name of the person that referred you to Define Dental so we can thank them!Please specifyMedical HistoryDo you have, or have you ever had any of the following? (Please tick if relevant) Blood disease eg Anaemia / Leukaemia Lung disease eg Asthma Cancer or related treatment Liver disease eg Hepatitis Allergy eg Penicillin / Latex Epilepsy Heart trouble of any kind High blood pressure Diabetes Kidney disease Thyroid disease Contact with HIV / AIDS Bone disease eg Osteoporosis Previous stroke Prolonged or excessive bleeding Prosthetic implant eg artificial hip Do you smoke? Are you, or might you be pregnant? Please provide details of any of the above conditions:Do you have any other medical condition NOT mentioned above?Please list ALL of the medication you take:Full payment is required at the time of treatment. As a courtesy we have HICAPS for processing private health insurance claims. Sometimes claiming is not possible due to issues with Your Health Fund. If this is the case, payments must be paid in full at your appointment. To make it as easy as possible for you, you will then be given a receipt so you may make a claim from your health fund. We accept payment by Visa, MasterCard, EFTPOS, Direct Deposit and Cash. I have completed this form to the best of my knowledge and acknowledge that this represents an accurate medical history. I have read and accepted the privacy policy.Signature*Date Date Format: DD slash MM slash YYYY For Parents/GuardiansI certify that the above medical and personal information is current and accurate. If there are any changes in future I will inform reception at Define Dental.Parent / Guardian SignatureDate Date Format: DD slash MM slash YYYY Privacy PolicyIn order to provide you with the highest standard of dental care, Define Dental is required to collect personal information from you. This information covers basic details such as your name, address, and telephone number. It is also necessary for us to obtain from you, details regarding your general health and past medical or surgical events. Without this general health picture, we are unable to plan your care properly. Naturally, some of this information is of a personal nature and some of it might be regarded as โsensitiveโ and not the sort of information that you would wish to be unnecessarily disclosed to others. At Define Dental, 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 in order to deliver your care to the highest standards. It will not be disclosed to those not associated with your treatment without your consent except as provided under the legislation and where we consider you would have a reasonable expectation of us to provide such information, for example if we refer you to a specialist practitioner, or if a laboratory is instructed to make a customised prosthesis for you. We may also use parts of your health information for research purposes, in study groups, at seminars or on our website as this may provide benefits to other patients. Should that happen, your personal identity will not be disclosed without your consent, to do so. You may seek access to the information held about you and we will provide this access without undue delay. This access might be by inspection of your dental records at the time of appointment or by special access or copying of information at other times. There will be no charge made for requesting this information but there may be fees levied to cover the costs associated with the processing of this request or the copying of the information. 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 reasonable steps to protect this information from misuse or loss and from unauthorised access, modification or disclosure. Our full Privacy Policy may be viewed on our website www.definedental.com.au or you may ask a member of our friendly reception team for a copy. Our team at Define Dental is 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 interests at all times. This iframe contains the logic required to handle Ajax powered Gravity Forms.
