www.smileinstyle.com.au - New Patient Registration

  • Patient Questionnaire Form

    Please note that it is important to fill in all the fields before submitting. Thank you.

  • Your Health Information - Privacy Consent Form

  • 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 Smile In Style ABN 84 930 850 453 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 below, as confirmation that you have read and understood the above information and consent to the collection and use of your health information.

  • Patient Information

  • Date of Birth*
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  • Would you like to subscribe to our newsletter?*
  • Are your teeth sensitive to*
  • Dental Visits: Preferred practice for appointments*
  • Does food catch between your teeth?*
  • Do your gums bleed when brushing or flossing?*
  • Do you notice an unpleasant taste or odour in your mouth?*
  • Have you had any complications during or following dental treatment?*
  • Have you had prolonged bleeding after tooth removal or dental surgery?*
  • Are you happy with the appearance of your teeth/gums/smile?
  • Would you like to discuss enhancing the appearance of your smile? *
  • Would you like to discuss how to make your teeth WHITE? *
  • Do you grind your teeth or clench your jaws?*
  • Have your jaw muscles ever been sore?*
  • Do you snore at night?*
  • Do you suffer from daytime sleepiness?*
  • Are you being treated for a medical condition?*
  • Are you taking any medications or supplements at present, both prescribed or over the counter?*
  • Are you taking any bisphosphonate medication or any other medication to treat osteoporosis?*
  • Do you have, or have you ever had, any of the following medical conditions?
  • Do you have allergies?*
  • Do you smoke?*
  • Do you Vape?*
  • Are you pregnant*
  • Undergoing fertility treatment?*
  • Date*
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  • Should be Empty: