Online Acquaintance Form

    This section is essential to us in providing safe medical treatment:

    Do you have any of the following? Please Tick

    Are you, or could you be pregnant?

    Do you smoke?

    Are you currently taking any medications or other drugs?

    Dental History

    What is you present dental concern

    Please Note:

    1. Payment for services is expected on the day of treatment

    2. We offer a variety of Finance Options (for approved applicants) including interest free terms and extended payment terms to commence treatment sooner

    3. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. There is no relationship between the doctor and the health fund. Any relationship with an insurance company is between the patient and their health fund.

    4. A minimum of 48 hours notice is required (unless specified otherwise) if there are any changes you would like to make to the appointment times given to you. Failure to do so will incur a charge of 250.00 per every half hour that you are booked in for an appointment.

    5. To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctor at the next appointment without fail. I understand that all health information given, will be treated with privacy and confidentiality. I have read the above conditions of treatment and agree to their content.