Medical history form

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Dear Patient,

We ask you to provide the following pre-treatment information. The information we collect enables us to provide you with better care. Your privacy is important to us, so all information provided will be kept strictly confidential. Please kindly take the time to complete the below information prior to your appointment.

YOUR DETAILS

Title:
First Name:
Last Name
Date of Birth:
Preferred Name:
Home Address:
Postal Code:
Mobile Phone:
Home Phone:
Email Address
How would you like to receive an appointment reminder?
How would you like to receive notification of special offers?
If you are under the age of 18 please state Father/ Mother/ Guardian's Names
Name of Parent / Guardian:
Contact No

BUSINESS CONTACT DETAILS

Your Occupation:
Business Name:
Work Phone
Business Address:
Postal Code

EMERGENCY CONTACT DETAILS

Name:
Contact No.:
Relationship to you:

DENTAL INFORMATION

What is the purpose of your visit:
When was your last dental check up?
Have you had any problems with past dental treatment?
If yes, please explain:
Do you have Private Health Insurance?
Fund?
Membership No.:
Ref No.:
Are you a Veteran Affairs Card Holder?
Card No. :
Date
Parent/Guardian Name / Signature
How did you hear about this practice?
To whom shall we make your accounts payable?

I have read and understand Beyond Smiles Privacy Policy. I understand that payment is required on the day of treatment.

My preferred method of payment is:
First Name:
Last Name:
Date of Birth:

CONFIDENTIAL HEALTH INFORMATION

Name of your Medical Doctor:
Contact No:
Address:
Are you being treated for a medical condition at present?

Do you have, or have you ever suffered from any of the following medical conditions? Please provide the approximate date of diagnosis if possible.

Do you have an allergic or adverse reaction to medication or treatments(i.e. Latex, Nickel, Penicillin,Codeine)?
Please Specify:
Do you carry medication with you that may be required during treatment or in case of an emergency?
Please Specify:
Do you have a neck or back problem that could be affected by your treatment?
Please Specify:
Please indicated the medications that you are currently taking or have recently taken?
Parent / Guardian Name / Signature:
Date:

TRADING TERMS

BETWEEN :
Beyond Smiles Mordialloc Trust trading as Beyond Smiles Dentistry ABN 67 286 931 853 (“the dentist”) and
(Name)
Address of Patient

General Terms

  1. All account relating to services rendered to be settled in full on the day.
  2. The valid and and current private health insurance card is required if your HICAPS claim is to be processed on the day, otherwise the full account needs to be settled.
  3. As of September 2012, all credit card payments will incur a 1.5% surcharge.

 

Other Terms

  1. If there is an outstanding account for any treatment, a recognized form of identification of the patient i.e Drivers license, will be required to be given to the Dentist. An arrangement will be made on a certain day (no more than 7 days) on which balance of the account will be settled in full.
  2. Failure to settle the account as promised will result in interest being charged at the rate of 6% per annum.
  3. If the account still remains unpaid, further and possibly legal action will be taken.( A minimum processing fee of $150 or 35% whichever is greater will be added to the outstanding account by the Dentist plus any other costs incurred in collecting the debt plus legal costs.)
  4. The patient acknowledges that in the case of default, by the Patient, the debt will be referred to a bad credit database.
  5. For better securing the payment of the monies outstanding the Patient hereby agrees, authorizes and consents to the Dentist registering a Caveat on any real estate owned by the Patient both present and future.
Date:
Signature of Patient
Name of Patient

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