Alcaston Dental Care Patient Registration

Patient Registration & Medical History Form

Please allow 10-15 minutes to complete this form.
Date of Birth*

DayMonthYear
Date
Preferred title
Preferred Name
Name*

Fast NameLast Name
Address*

Street Address

Street Address Line 2

SuburbState

Postal / Zip Code
Phone Number*
Email*
example@example.com
Parent / Guardian Name / Carer (If applicable)
Parent / Guardian Name / Carer
Emergency Contact Name*
Emergency Contact Phone Number*
Person responsible for the fees?*

SelfOther, please specify below:
Name
Address

Street Address

Street Address 2

SuburbState

Post Code
Phone number

How did you hear about us?*
Do you have health insurance? If so, who are you with?*
(Eg: Bupa, Medibank, AHM, etc)
Are you eligible for the Child Dental Benefits Schedule (CDBS)?*

YesNo
Medicare Number / REF
Please enter a valid phone number.
Department of Veterans Affairs' Card Number (If Applicable)
Is this consultation related to Workcover or a Work related injury or Transport Accident*

YesNo
Privacy Policy

Please take care to fill out this form completely. We rely on all your information to be able to provide you with appropriate dental services. 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.
Would you like to receive appointment reminders?

NoSMSEmailPhone Call

Allergies and Adverse Reactions
Do you have any allergies?*

NoYes, Please specify:
Do you have any adverse reactions to drugs?*

NoYes, Please specify:
Allergy Emergency Plan

Medicines
There are many medications that may impact upon your oral health or the treatment we plan for you. Please indicate any medications that you are currently taking or have taken recently (including natural therapies). Alternatively, a list from your GP can be attached.
File Upload

Cancelof
Are you on any blood thinners such as Warfarin or Aspirin?*

YesNo
Is there anything else you would like to discuss in private?*

YesNo

I agree I am to be responsible for all payment of fees and understand that payment is due at the time of the service.
Signature*

Clear
Date*

DayMonthYear

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 Alcaston Dental Care trading as Alcaston Dental Care 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 take reasonable steps to 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.
I have read and understood the above information and consent to the collection and use of my health information.
Name*

First NameLast Name
Dependents
Signature*

Clear
Date*

DayMonthYear
Date

Booking and Cancellation Policy - Acknowledgement
New Patients

A $75* deposit will need to be paid to secure a new patient booking. Once new patients are booked in, all scheduling and cancellation policies are applicable.

Rescheduling + Cancellation

Notice period
We require at least 24 hours’ notice prior to your appointment for cancellations and rescheduling.

Regular bookings
Failure to provide sufficient notice will require a $100* deposit to book another appointment.

Bookings with a paid deposit
Failure to provide sufficient notice will result in the deposit being forfeited and become a cancellation fee. A new $100* deposit will then be required to book another appointment.

Running late

If running less than 15 minutes late, please inform the clinic as soon as possible. This may result in a shortened appointment time to avoid delays for other scheduled patients.

If running more than 15 minutes late, your appointment will need to be rescheduled and a $100* deposit will be required to book another appointment.

If you arrive more than 15 minutes late without notice, a $100^ cancellation fee will be charged, and a $100* deposit will be required to book another appointment.

No shows

Failure to show up at your appointment without notice will result in a $100^ cancellation fee and a $100* deposit will be required to book another appointment.

Exceptions

We understand that emergencies and unforeseen circumstances can take place such as sudden illness, accidents or family emergencies. Please get in touch with us as soon as possible to reschedule your appointment.

* all deposits mentioned are non-refundable and will be deducted from the total cost of your treatment at your next appointment.

^ cancellation fees are not deposits and will not be deducted from the total cost of your treatment.
I have read and understood the booking and cancellation policies, and I acknowledge that these policies apply to me as a new patient at Alcaston Dental Care.
Name*

First NameLast Name
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty:

Patient Registration & Medical History Form

Privacy Policy

Medical History

Allergies and Adverse Reactions

Medicines

Your Health Information - Privacy Consent Form

Booking and Cancellation Policy - Acknowledgement