Client Acquaintance Form

Client Acquaintance Form

    Title

    First Name

    Last Name

    I Prefer to be Called:

    Date Of Birth *

    Mobile *

    Home Phone

    Work Phone

    Preferred Contact No

    Preferred Contact No

    How would you like to receive appt reminders? Copy

    Address (Residential)

    Address (Postal)

    Do you have Private Health Insurance with Dental Cover?

    If yes, which fund?

    Are you eligible for Medicare CDBS Scheme? (patients 2 – 18 years old)

    If yes, please advise reception prior to the appointment.

    Medical Doctor Name

    Contact Number

    Emergency Contact

    Contact No.

    Relationship to you

    How did you find out about our clinic?

    Friend or Family (please list name)

    Other

    Are you Pregnant?

    Are you currently Breast feeding?

    Do you Smoke?

    Do you Snore?

    Play contact sports?

    Please list any allergies (Medication, Penicillin, Latex etc)

    Please list any medications (including herbal and prescribed)

    Have you EVER had any of the following

    Do you now or have you recently suffered from any of the following

    Other medical details to be included?

    Are you experiencing any of the following

    Consent for Services

    To the best of my knowledge, the preceding answers and all information provided are true and correct. Should I have any change in my health status or personal details, I will inform the doctor at my next appointment, without fail. I understand that notes, radiographs (x-rays) or models relating to my treatment may need to be sent to other practitioners to aid them in my treatment and consent to this. I understand that dental treatment must be paid in full at the time of treatment. I acknowledge that if an account is overdue The Smile Place Mt Eliza reserve the right to refer the account to a third party. I agree to meet all reasonable costs incurred by The Smile Place Mt Eliza in employing the said third party, to collect the overdue account.

    I understand that if I do not give at least 24 hours’ notice a cancellation fee may be charged.

    I Accept

    Your Name

    Relationship to child if Parent or Guardian

    Date