Patient Consent FormWelcome to Camberwell Orthodontic GroupStep 1 of 911%FacebookThis field is for validation purposes and should be left unchanged.PasswordPlease 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 Dr.MasterMissMr.Mrs.Ms.Mx.Prof.Rev. First Last Preferred Name:Date of Birth: DD slash MM slash YYYY Address: Street Address Address Line 2 Suburb Post Code Phone:Mobile:Patient Email:(Required) Enter Email Confirm Email Do you have Dental Health insurance?(Required) Yes NoHealth insurance Fund:Are you of Aboriginal or Torres Strait Islander origin? Yes NoParent/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 NoDo you suck your thumb or fingers? Yes NoHave you had any accidents resulting in mouth injury? Yes NoHave you had your tonsils or adenoids removed? Yes NoDo you have difficulty breathing through your nose? Yes NoDo you play a brass or woodwind musical instrument? Yes NoAre you sensitive to latex, rubber or nickel? Yes NoDo you have any allergies, illnesses or syndromes? Yes NoPlease List:Do you identify as a person with a disability? Yes NoPlease Describe:Do you identify as a person from a culturally and linguistically diverse background? Yes NoPlease Describe:Medical HistoryHIV or Aids? Yes NoRheumatic Fever? Yes NoDiabetes? Yes NoHeart Ailment? Yes NoEpilepsy? Yes NoHigh Blood Pressure? Yes NoAsthma? Yes NoHepatitis? Yes NoChest Problems? Yes NoDrink Alcohol? Yes NoSmoke? Yes NoAre you currently taking any drugs or medication? Yes NoPlease List:Have you had major surgery? Yes NoPlease List:Are you currently under the care of a doctor or other health professional? Yes NoPlease List:Do you wish to add anything further?Privacy & Consent(Required)PRIVACY POLICYYour 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.SignatureName of patient or authorised guardian.(Required) First Last Date(Required) DD slash MM slash YYYY
