• Patient Health Questionnaire

    Please complete the form below
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  • Emergency Contact Details

  • Medical Questions

  • Have you ever had, or been treated for any of the following conditions. Please tick "yes" or "no"
  • Do you have or are you at risk contracting any of the below:
  • AGREEMENT

  • Our Commitment to you: At all times we will provide you the very best dental care available in a modern, friendly environment. As a patient at Bays Dental, your well-being is our first priority. Your details are kept safe (as per the Privacy Act) and is only collected with the purpose of providing you with the best and safest possible treatment and to assist in the administrative aspects of care-giving (as required by the Dental Council of NZ)

  • Your Commitment: I, the undersigned, agree to be responsible for payment of all services rendered on my behalf or on behalf of my dependents. I understand that payment is due at the time of treatment, unless other arrangements have been finalised. A 15% fee may be added to outstanding amounts. If required for debt collection, I understand that any costs incurred while debt collecting will be on-charged to me and that a check of my credit history may be made, and/or my details may be passed to a third party. I understand that by making appointments with Bays Dental, I am agreeing to attend the appointments or to give a minimum of 24 hours’ notice of cancellation of appointments. If I fail to attend an appointment, a ‘no show’ fee of $50 per half hour of the appointment may be charged.

  • Should be Empty: