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Patient Registration Form

The Dental Gallery
3 Newminster Way
Point Cook Vic 3030
T 9395 8338

Welcome to The Dental Gallery. Please fill in all blank lines and please fill in all appropriate boxes. If the patient is under 18 years of age a parent, adult or guardian is required to complete this form.

Preferred title:
First Name: Last Name:
Preferred Name:
Address:
Suburb/Town: Postcode:
Home Phone: Mobile:
Work Phone: Email:
Date of Birth:
How did you find out about our practice:
How would you like to receive an appointment reminder?:

If you are under 18 years of age, please state Father / Mother / Guardian’s name:

If relevant, Carer name: Phone:
Emergency Contact Name:
Phone: Mobile:
Who is responsible for the account?

Are you eligible for the Child Dental Benefits Schedule (CDBS)?
Department of Veterans Affairs’ Card Number:
Is this consultation related to Workcover or a Work related injury or Transport Accident?

Privacy Policy – We collect the information set out above in order to provide you with dental services. We will keep your information secure and confidential. If necessary, we may pass your information on to other health practitioners for a second opinion or referral purposes. We may also be required by law to provide your information to outside agencies. Our complete Privacy Policy is available at reception.

Terms of payment – The Dental Gallery accepts payments in cash, Eftpos, Visa and Mastercard. The fees are charged and payable on the day. We are not affiliated with any private health fund, therefore health fund claims and rejections are the responsibility of the patient.

Disclaimer – Dentistry is not an exact science, and outcome of every dental treatment depends on multiple factors, such as the medical health of the patient. We will always explain the risks and possible complications involved for each procedure. However, some are unforeseeable. For this reason dental diagnosis and procedures cannot be guaranteed. Nevertheless, our team will engage every effort possible to achieve the highest standard of results.

By signing this form, I the patient/person responsible for the patient, have read and understood all the information stated above. I have also filled in this form to the best of my knowledge and ability, as honestly and accurately as possible. Therefore, I give my consent for The
Dental Gallery to look after the patient for his/her dental needs.


Patient’s Family Doctor:
Address:
Telephone:
Please answer the following to allow us to find out a little more about your dental health:
What is the reason for your visit today?
When was your last visit to a dentist?
Do you usually have regular dental check-ups?
How often do you brush and floss your teeth?
Do you smoke?
Is there anything about dentistry that bothers you?
Are you happy with the appearance of and the way your teeth function?
Please tick the boxes if you have or ever had the following medical conditions:

If yes to any of the above, please elaborate:
Are there any other medical conditions that you may have?
Please list all medications you are currently taking:
For women only: Are you pregnant? If yes, how many weeks? Are you nursing?
Please tick if you are aware of the possibility that you may have the following high risk conditions:

If yes to any of the above, please elaborate:
I have answered all questions to the best of my knowledge. Should further information be required, the practice has my permission to request them from the respective health care provider. I understand that the information I have provided is important for the delivery of my dental treatment in a safe manner within this practice. I understand that this document will be treated in the strictest confidence by the practice. Our complete Privacy Policy is available at reception.

Signature(upload here): Date: