• Patient Information Form

  • PRIVATE HEALTH INSURANCE/MEDICARE

  • Health Insurance*
  • Type of cover:*
  • Is your child eligible for the Child Dental Benefits Scheme?

  • PREFERRED CONTACT

  • Preferred contact method:*

  • REFERRAL

  • How did you hear about our clinic?*
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  • MEDICAL HISTORY

  • Does your child have a personal General Practitioner?*
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  • In the last 2 years, my child's medical contacts have been:*
  • My Child is generally fit and healthy.*
  • Has your child ever had any of the following?*

  • Is your child taking any medication?*
  • Does your child have any allergies, including latex, medications, foods, etc?*
  • Has your child ever had an operation or been in hospital overnight?*
  • Has your child or any family member had complications under general anaesthesia?*
  • Has your child have a history of COVID-19?*

  • DENTAL HISTORY

  • Is this your child's first visit to a dentist?*

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  • If your child has seen a dentist previously, have they had any of the following?*
  • Is your child attending another Dental/ Medical Specialist?*
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  • What is the reason for today's visit?*

  • Have there been any recent injuries to the teeth, face, or mouth?*
  • Does your child think there is anything wrong with their teeth?*
  • How frequently are your child's teeth brushed?*
  • Who does this?*

  • Toothpaste used?*
  • Toothbrush used?*
  • Does your child floss daily?*
  • Does your child have any of the following habits?
  • Is your child breast/bottle feeding?*

  • PARENT/GUARDIAN DETAILS


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  • OTHER PARENT/GUARDIAN:


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  • Parents Marital Status

  • Are details of this child's dental appointment able to be shared with the secondary parent/guardian?
  • Should communications be sent to the secondary parent/guardian as well?

  • HEALTH DECISIONS FOR YOUR CHILD

  • Are there any custody issues, which may affect your child's treatment and/payment of accounts?*

  • Who has legal responsibility for health decisions about your child?:*
  • Is this patient a foster child?
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  • CONSENT/PRIVACY/RECORDS RELEASE INFORMATION

  • In accordance with the Privacy Act (1988), all information collected by Tooth Town is treated as confidential. To protect your privacy and that of your child, Tooth Town operates in accordance with this act. We may use the information provided in the following ways:

    • Disclosure to others involved in your child’s health care, including other health practitioners and hospital administration. This may occur through referral to other health practitioners.

    • Disclosure to a medical defence organisation if a medico-legal matter arises.

    • Clinical Teaching.

    • Sending SMS appointment reminders via mobile phone using the numbers provided by you.

    • Leaving voicemails identifying the caller, using the numbers provided by you.

    • Sending correspondence via email using the email address provided by you.

    • Administrative purposes in running our practice including debt management agencies if required.

    • Utilisation of photographs and other images including x-rays for clinical teaching.

    PARENT/GUARDIAN CONSENT

    I have read the information above and understand the reason why my child’s information must be collected. I am also aware that Tooth Town has a privacy policy on handling patient information.

    I understand that I am not obliged to provide information requested of me, but failure to do so may compromise the quality of dental care/health care and treatment given to my child.

    I am aware of my rights to access information collected about my child, except in some circumstances where access might be legitimately withheld.

    I understand I will be given an explanation in these circumstances. I understand that if information is to be used for any other purpose other than set out above further consent will be obtained.

    I have authority to consent on behalf of my child. I consent to examination, x-rays, treatment, collection of clinical records (including clinical photographs). I consent to the handling of my child’s information by Tooth Town for the purposes set out above.

    FINANCIAL

    I will be responsible for any financial obligation incurred for my child’s treatment, and for incidental costs incurred and or legal fees necessary to recover the same. I understand that all accounts will be settled at the time of appointment. A minimum of 24 hours’ notice is required for any appointment changes.

     

  • Photo Consent*
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