Online Patient Form

PATIENT MEDICAL HISTORY

These details provide us with information required for your optimal dental treatment and oral health care.
Your Privacy & Confidentiality will be respected at all times. It may sometimes be necessary to consult with other health professionals.
Please feel free to discuss any health questions in confidence with your Dentist.

1. I hereby authorise the dentist or designated staff to take X-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a through diagnosis.

2. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3. I agree to the use of anaesthetics, sedatives and other medication as necessary. I fully understand that using anaesthetics agents embodies certain risks. I understand, I can ask for a complete recital of any possible complications.

4. I agree to be responsible for payment of all services rendere on my behalf and on behalf my dependents. I understand that payment is due at the time of service unless other arrangements have been made.

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