In Facility Dental Care Patient Consent Form

In Facility Dental Care Patient Consent Form
Patient's Details
Facility Name*
Facility Suburb*
Patient's Name*

PrefixFirst NameLast Name
Preferred Name
Date of Birth*

DayMonthYear
Please enter date of birth in DD-MM-YYYY format.
Gender*
Mobile Number*
Email
example@example.com
IMPORTANT : To prevent a delay in booking the dental appointment, a copy of the patients medication charts and diagnosis summary (including surgical history) must be provided by the facility 5 days prior to the scheduled dental visit.
Residing Address*

Street / Unit / Apartment Number

Street Name

SuburbState

Postcode
Emergency Contact
Name

First NameLast Name
Mobile Number*
Medical and Financial Consent
Medical consent provide by?*

PatientLegally Authorised Representative
Financial consent provided by?*

PatientLegally Authorised Representative
Legally Authorised Representative's Details

Authorised representative for medical and/or financial decisions
Legally Authorised Representative's Name*

First NameLast Name
Legally Authorised Representative's Mobile Number*
Relationship to the Patient*
Legally Authorised Representative's Email
example@example.com
Dental Appointment Details
Is the patient able to walk with assistance?*

YESNO
If NO, please give details on what assistance is required.
Will any person/s be attending the dental appointment other than the patient?*

YESNO
If YES, please provide details about person/s attending
Does the patient have any particular dental concerns/issues?*

YESNO
IF YES, please give details about the dental concerns/issues
Does the patient have (please select multiple options if required)*

Natural TeethPartial DenturesFull Dentures
Treatment Selection
Please select at-least on treatment option*

Dental Assessment - Comprehensive Examination, Oral Hygiene Instructions, Ultrasonic Scale, Clean and FluorideDenture Examination - Exam of Gums and Review of Denture FitOral Examination General Oral Check-Up Only
PAYMENT : We require pre-payment prior to the scheduled dental visit.
HOW TO PAY : We do not collect or store credit card information. A secure Tyro Health payment link will be sent to the patient's or legally authorised representative's registered mobile number three (3) days before the scheduled dental visit.
REFUNDS : Should we be unable to provide the services for any reason, a full refund will be processed on the same day
Patient's Medical History

Does the patient have (or have they had) any of the following conditions? Please tick YES or NO.*

	YES	NO
Heart trouble of any kind
High blood pressure
Epilepsy
HIV (AIDS)
Rheumatic fever
Difficulty swallowing
Dementia
Requires blood thinners
Asthma
Diabetes
Osteoporosis
Pregnancy
Smoker (current / past)
Recreational drug use (if any)

Any allergies?*

YESNO
If YES, please provide allergy details*
Currently taking medication?*

YESNO
If YES, please provide medication details*
Hepatitis A, B or C?*

YESNO
If YES, please provide Hepatitis A, B or C details*
Has the patient had surgery in the last six months?*

YESNO
If YES, please provide surgery details*
Signature
I confirm that I am either the patient or the patient's legally authorised representative (e.g., guardian, or holder of an enduring power of attorney for health matters) and have the authority to provide consent on their behalf. I hereby give informed consent for The Smiles Dentacare (TSD) to collect, use, and disclose my personal and health information as necessary to provide dental care and treatment. I understand the nature of the dental treatment, the potential risks involved, and that I may ask questions or withdraw my consent at any time. I acknowledge that if any further treatment is required, the treating clinician will discuss the recommended options with me or, where applicable, my legally authorised representative, and that consent will be obtained before any additional procedures are performed. I confirm that the information I have provided is true, accurate, and complete to the best of my knowledge.
Patient
Patient's Name*

First NameLast Name
Date*

DayMonthYear
Automatically selects today's date.
Patient's Signature*

Clear
Legally Authorised Representative
Legally Authorised Representative's Name*

First NameLast Name
Relationship to the Patient*
Date*

DayMonthYear
Automatically selects today's date
Legally Authorised Representative's Signature

Clear
Should be Empty:

In Facility Dental Care Patient Consent Form

Patient's Details

Emergency Contact

Medical and Financial Consent

Legally Authorised Representative's Details

Dental Appointment Details

Treatment Selection

Patient's Medical History

Signature

Patient

Legally Authorised Representative