Forms

Child Benefits Schedule Bulk Billing Patient Consent Form

Patient Registration Form

Patient Registration Form
Gender

Parent Details

This section for parent's of children only


End children's section


Aboriginal & Torres Strait Islander
Private Health Fund
Would you like to receive a reminder for your appointment?
Is this consultation related to Workcover or Work-related Injury?

Please read carefully and answer the following questions about your health and tick the relevant answer. Do you currently have or have you ever had any of the following:

Surgical operation under General Anaesthesia?
Reaction to General Anaesthesia?
Arthritis
Back or Neck Problems?
Diabetes
Heart Condition or Surgery?
Pacemaker?
High Blood Pressure
Hepatitis B
Hepatitis C
Kidney Disease?
Osteoporosis?
Osteoporosis On Medication
Are you pregnant?
Do you smoke?
llicit Drugs?
Are you on Methadone Program?
Do you have any allergies?
Allergies
Have you ever had any complications after dental treatment?
Any dental fear or phobia?
Anxiety/Depression?
Asthma
Other Respiratory Disease?
Cancer
Heartburn, Acid Reflux or other Digestive System Problem?
HIV/AIDS
Infectious Disease?
Nervous System Condition?
Sensory Problems?
Thyroid Disease?
Autism?
ADHD?
Learning Delay?
Speech Delay?
Stroke?
Alcohol?
Are you on any other regular medications?
Allergies
Any other conditions?

Consent


I give consent for medical information to be obtained by my dentist for the purpose of my dental treatment and passed on to a third party for further treatment if required.
I give consent to release my results to my designated relative/carer.
I give consent for my contact details to be obtained for the purpose of contacting me regarding medical matters or appointments.

Medical practitioners at Diggers Rest Medical Centre are committed to providing our patients with the best care. To do this it is essential that your health records are kept up to date and accurate. We recognise the importance of privacy and confidentiality for all our patients. Acknowledgement:


I acknowledge that all the information provided in this form is true and correct.
I agree to be responsible for all payments and will pay the amount due at their due time. I have read Payment Policy below.

Person responsible for the fees


Payment Policy:

Our practice policy is to provide our valued patients with an estimate of their dental treatment cost before commencement. This may be completed verbally by our friendly dentists or nurses, and recorded in our notes, especially if urgent treatment is being performed.

As we are a private practice, payment for our dental service must be paid on the same day, otherwise will incur a fee of $75 for patients who do not meet these requirements.

We offer patients a range of payment options including:

  • Medicare (for eligible patients only)
  • Private Health Funds
  • DVA
  • Afterpay
  • ZIP

A non-refundable deposit may be required prior to major dental treatments.