Paynesville Dental Centre » Your First Visit

Surname*

Given Names*

Preferred Name*

Gender*

Male
Female

Date of Birth*

Phone*

Alternate Phone*

Prefer contact by SMS?

Yes
No

Email

Postal Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal Code

Residential Address*

Street AddressAddress Line 2CityState / Province / RegionZIP / Postal Code

Do you have private health cover for dental?*

Yes
No

Please name your fund*

Do you have a Veteran's Affairs Card?*

Yes
No

Please provide VX number*

Please indicate Gold or White card?*

Gold
White

Indicate any medical conditions that apply to you

Please describe your other illness*

Are you a smoker?*

Yes
No

Are you taking any bisphosphonate medications? *

Yes
No

eg. Osteoporosis medication etc.

Do you have any allergies/sensitivies? *

Yes
No

eg. penicillin, antiseptics, iodine etc.

Please list your allergies and sensitivities*

Are you pregnant?*

Yes
No

How many months?*

Doctor's Name*

FirstLast

Medications Taken (prescribed and non-prescribed)*

Write 'none' if you are not taking medication.

Medicare Number

Privacy Policy

Paynesville Dental Centre Privacy Statement
To collect personal information we need your consent. This form outlines why we must collect this information and how we may use it.

Why we collect your personal information 
The information we collect is used for the primary purpose of providing quality health care. We need you to provide us with your personal details and some medical history so that we may properly assess, diagnose and be proactive in your health care needs.

What will happen with your personal information
Your information will be used in the following ways; administrative purposes in running our practices, billing and legal requirements (including, compliance with Medicare, Health Insurance Commission and Veteran's Affairs), disclosure to others involved in your health care include treating doctors's and specialists.

Disclosure of your details
To ensure optimal health care, access to a patient's health information is required by all members of a medical team. To ensure quality and continuity of patient care, a patient's health information may need to be shared with other health care providers from time to time. It is necessary to keep patient's information after their last attendance for as long as it is required by law. The personal information we collect is handled in accordance with the privacy legistlation.
Is your information safe?
Your information is kept secure, where only authorised personel may access the information. All records remain the property of Paynesville Dental Centre.

Form Privacy Policy Consent*

I have read the above privacy policy and understand why my information must be collected. I consent to my information being handled in the matter set out above. I understand that I have the right to access my information as set out above.

Patient Information Form