CONSENT FOR SERVICES
- I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetic and other medication as indicated and I will assume responsibility for the fees associated with the procedures.
- I understand that the practice requires at least 24 hours notice if I need to reschedule or cancel my scheduled appointment and that a cancellation fee may be incurred if I fail to do so.
- I hereby authorise the dentist or the designated team to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.
- I am aware that payment is required on the day of treatment.
- We provide as a courtesy to our patients, a preventative recall program that offers a call service if you have not been to the practice in 6 months.
PRIVACY POLICY
Our practice respects your right to privacy. We realise that it is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our practice and to whom this information might be disclosed.
The policy of our practice is to follow these procedures:
The information collected will be used for the purpose of providing treatment to you. Personal information such as your name, address and health insurance details will be used for the purpose of addressing accounts to you, as well as processing payments and writing to you about our services and any issues affecting your treatment.
- We may disclose your health information to other health care professionals, or require it from them if, in our judgement, that is necessary in the context of your treatment. In that event, disclosure of your details will be minimised wherever possible.
- We may also use parts of your health information for research purposes, in study groups or at seminars as this may provide benefit to other patients. Should that happen, your personal identity will not be disclosed without your consent to do so.
- Your medical history, treatment records, x-rays and any other material relevant to your treatment will be kept here. You may inspect or request copies of our records of your treatment at any time, or seek an explanation from the dentist. Statutory fees will apply in relation to the types of access you seek. If you request an explanation of our records or a written summary, our usual fees apply to these services.
- If any of the information we have about you is inaccurate, you may ask us to alter our records accordingly.
- You can otherwise rest assured that your health information will be treated with the utmost confidentiality. Disclosure will not be made to any person not involved in either your treatment or the administration of this practice, without your prior written consent. If you have any queries or concerns about our handling of your health information, please do not hesitate to raise these concerns with our practice.
Otherwise, please sign this form that you have read and understood our privacy policy, and consent to the use of your health information in this way.
I have completed this Questionnaire to the best of my knowledge, and understand that failure to make a full
disclosure may place me at undue risk.
