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Are you pregnant? Details: Details: PATIENT / PARENT / GUARDIAN SIGNATURE: Details: NoDetails: Do you smoke? Details: Bleeding Disorder: Creutzfeldt- Jakob Disease (CJD):Details: Details: Allergies / Adverse Drug Reactions: FEES, RESCHEDULING AND CANCELLATIONSHepatitis / HIV: Heart Problems / Rheumatic Fever: Asthma / Lung Condition: YOUR HEALTH INFORMATION - PRIVACY CONSENT FORM Please List any other medical conditions: Details: Yes
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PARENT / GUARDIAN NAME (If Applicable): PATIENT NAME:Details: Are you breastfeeding?Epilepsy: Occupation:MEDICAL CLINIC: MEDICAL CLINIC: CONTACT NUMBER: YESMEDICAL HISTORY FORM DENTAL HISTORY PATIENT INFORMATION FORM NOPlease indicate if you have any of the following: Surname: Name: Tuberculosis (TB):When was your last dental visit? OTHER: Would you like to discuss or find out more about any of the following? Invisalign For Children: Have you received a letter that your child is eligible for Medicare Child Dental Benefit Schedule (CDBS)? Medicare Number and Reference Number: Relationship:(H):Email:Address:Contact Number:• Our practice respects your right to privacy and it has systems and processes in place to ensure it complies with the Australian Privacy Principles (APPs). The practice privacy policy is available on request.
• Our practice Khachornwut Supasiti (ABN 80 215 297 174) trading as Supa Dental Pty Ltd 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 the APPs.
• The practice Privacy Officer can be contacted at the practice during business hours if you have any concerns or questions about a privacy matter.
Please sign this form as confirmation that you have read and understood the above information and consent to the collection and use of your health information.
Phone: Details: Joint Replacement Surgery: Title:Given name(s):Date of Birth: Preferred Name:Emergency Contact Details: Heath Fund for Dental: Post Code:Details: Member Number: RE-SCHEDULING, CANCELLED OR MISSED APPOINTMENTS: At least 24 hours’ notice is required when changing an appointment. If notice is received less than 24 hours before your appointment or should you miss your appointment altogether, you will receive an $80 fee
FEES: Payment for treatment is expected on the day of your appointment. Failure to pay your account may result in your account being forwarded to Prushka Fast Debt Recovery Pty Ltd. *In the event that you default in making payment and recovery action is undertaken, you will be responsible for all expenses in relation to the collection of the outstanding amount including but not limited to, all fees and charges, legal costs on an indemnity basis, and disbursements.
DEPOSITS: Appointments scheduled for more than 1 hour require a deposit of $200. This deposit will be deducted from the cost of your treatment or refunded to you once the appointment has been attended and completed. The deposit is non-refundable in the event the appointment is rescheduled or cancelled.
PAYMENT PLANS: By agreeing to a payment plan at Supa Dental you enter an agreement with DentiCare Payment Solutions Pty Ltd and you acknowledge and agree that your scheduled direct debit payments and entire payment plan remains your financial responsibility until the entire payment plan is paid in full. It is your responsibility to ensure your payment plan has been processed by DentiCare Payment Solutions Pty Ltd prior to your first payment. If a scheduled direct debit fails for any reason, it is your responsibility to contact DentiCare Payment Solutions Pty Ltd regarding this issue. Failure to complete your payment plan may result in your account being forwarded to Prushka Fast Debt Recovery Pty Ltd.
Have you taken or are you taking Fozamax or Actonel? What is the primary reason for your appointment today? FAMILY / FRIENDBraces Teeth Whitening/Bleaching Mouthguards or Nightguards Crowns, Bridge, or Veneers Teeth grinding or Clenching Replacement of missing teeth Comestic Dentistry Who should we thank for your referral? Diabetes: How did you find out about Supa Dental? Please list any medications you are currently taking? How many per day:High Blood Pressure: FACEBOOK DRIVING PASTDATE: GOOGLEDetails: Have you recently been exposed to Measles, Mups, Chicken Pox or Whopping Cough?