Patient Consent - Camberwell Orthodontic Group

Phone

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Password

Please enter the password before filling out the following sections, or clicking 'Next'.

What is your main concern and main reason for seeking an orthodontic consultation?

How do you/ your child feel about visiting the orthodontist?

Patient Name

Prefix First Last

Preferred Name:

Date of Birth:

Address:

Street Address Address Line 2 Suburb Post Code

Phone:

Mobile:(Required)

Patient Email:(Required)

Enter Email Confirm Email

Do you have Dental Health insurance?(Required)

Yes

Health insurance Fund:

Are you of Aboriginal or Torres Strait Islander origin?

Yes

Parent/Guardian details (if under age):

First Last

Parent/Guardian 2:

First Last

Person/s responsible for fees (if different from above):

First Last

Address:

Street Address Address Line 2 Suburb Post Code

Emergency Contact:(Required)

First Last

Phone:(Required)

Emergency Contact Address:(Required)

Street Address Address Line 2 Suburb Post Code

Whom can we thank for referring you to our practice?

(Friend, Family member, Internet etc.)

Name and address of Dentist:

Have you had braces or worn a plate before?

Yes

Do you suck your thumb or fingers?

Yes

Have you had any accidents resulting in mouth injury?

Yes

Have you had your tonsils or adenoids removed?

Yes

Do you have difficulty breathing through your nose?

Yes

Do you play a brass or woodwind musical instrument?

Yes

Are you sensitive to latex, rubber or nickel?

Yes

Do you have any allergies, illnesses or syndromes?

Yes

Please List:

Do you identify as a person with a disability?

Yes

Please Describe:

Do you identify as a person from a culturally and linguistically diverse background?

Yes

Please Describe:

Medical History

HIV or Aids?

Yes

Rheumatic Fever?

Yes

Diabetes?

Yes

Heart Ailment?

Yes

Epilepsy?

Yes

High Blood Pressure?

Yes

Asthma?

Yes

Hepatitis?

Yes

Chest Problems?

Yes

Drink Alcohol?

Yes

Smoke?

Yes

Are you currently taking any drugs or medication?

Yes

Please List:

Have you had major surgery?

Yes

Please List:

Are you currently under the care of a doctor or other health professional?

Yes

Please List:

Do you wish to add anything further?

Privacy & Consent(Required)

PRIVACY POLICY

Your right to privacy is respected by “Camberwell Orthodontic Group”. We would like you to understand why we collect your health details as well as how our practice uses this information, and to whom this information may be disclosed.

Our practice policy is:

The purpose of collecting the information is to use it whilst providing treatment to you. Personal information including your name and address will be used to address accounts, process payments and write to you about our services and your treatment.

Your health information may be disclosed to other health care professionals or we may retrieve it from them if it is necessary for your treatment. If this is necessary, disclosure of your personal details will be kept to a minimum.

We may also use parts of your health information for research purposes to benefit our services to patients. Your personal identity will not be disclosed without your consent.

We keep records of your medical history, x-rays and any other relevant information regarding your treatment. You may request copies of your records or x-rays at any time or seek an explanation from the Orthodontist.

You may ask us to alter our records if any of the information we have about you is incorrect.

It is important for you to know that your health information is treated confidentially. Your personal health information will not be disclosed without your prior written consent to any person not involved in either your treatment or the practice administration. If you have any queries or concerns, please do not hesitate to discuss with us.

I HEREBY CERTIFY THAT:

1) I have read an outline of the Privacy Policy and I fully understand these.

2) I acknowledge my payment responsibilities and agree to pay “Camberwell Orthodontic Group” for orthodontic examination and any subsequent treatment.

I agree.

Signature

Your Name
Your Name
Your Name

Name of patient or authorised guardian.(Required)

First Last

Date(Required)

Patient Consent Form

Medical History

PRIVACY POLICY

I HEREBY CERTIFY THAT: