This form gathers crucial personal information of any medical conditions, medications, or other factors that could impact your orthodontic treatment. Rest assured that all information is managed with the utmost confidentiality and care.
If you're uncomfortable providing certain details, please let us know so we can discuss them with you privately.
Please tick if you currently have or previously had any of the following
My / My child’s concerns with my smile are: (please tick the relevant boxes below)
Orthodontic records including x-rays, photographs, clinical details, medical and dental history, and personal information are necessary to provide you the best orthodontic care in our practice. Occasionally it may be necessary to provide your information to relevant third parties. Examples of this would be your health fund asking for the date treatment commenced, a friend or relative confirming appointments, etc.
Your records may also be used for consultation with other medical and dental professionals in order to provide you with the best and most up to date treatment possible.
As well as being required for orthodontic and legal purposes your records can be useful for education, professional peer review and research purposes. Individual patients are never identified and your privacy and anonymity are protected.
Care is taken to ensure that your records are handled with confidentiality and sensitivity according to guidelines developed from the Privacy Act 1988.
If you wish to vary this consent we will require written advice from you.
Use the space below to note any specific requirements you have regarding how your personal information is used.
Please also specify (if any) persons who must not be provided with information regarding your treatment.
If you understand and accept the above, please sign below to show your consent. (If patient is under 18 a parent or guardian must sign and print their details on behalf of the patient)
I understand that failures to appointments without at least 48 hours notice will incur a no-show fee of $70.
For further information about how we use your data, please see our privacy policy.