Patient Registration Form [#F003-PR-112017-V-1]
1General Info
2Personal Details
3Medications
4Medical History
5Insurance & Subsidy
6Declaration

ADHPL ("the practice") collects, stores, uses, discloses and treats all your presoal, private and confidential information including your dental and health records with due care and delignce as required under the prohivision of the Australian Privacy ACT 1988 and in conformance wit its 10 National Privacy principals (NPP) and as per the professional guidelines contained within the AHPRA's Health Practitioner Code of Conduct (March 2014). For further details please review our Privacy Policy 2015 or Privacy Policy 2015 displayed on the Wall Mounted Notice board located in the Waiting Area of our practice.

This questionnaire is designed to collect and provide ADHPL and its staff your personal, private and confidential information including your personal and contact details, dental and medical history, and current state of health and dental concerns, private health fund and Medicare/GP details etc.. You may also be asked to provide other supporting documents and information for our / dentists’ clarification and verification purposes as necessary including transfer of records from your previous practitioners (where applicable). During the course of your dental diagnosis and treatment, the dentist may, subject to your written or verbal or implied consent, take extra- and intra- oral images and X-rays/OPG/CBCT, diagnostic models/ intra-oral scans, videos and snapshots, oral cancer screening, digital tooth shade guide, digital occlusal scanning and analysis as deemed necessary for gathering evidence of your pre and post-operative oral condition including for complex cases, further conducting or refer you to appropriate expert/specialist for smile design, virtual articulation, Invisalign, root canals, extractions, dentures, implants & other oral assessment and treatment.

You have the right to receive proper, fair and equitable general and specialist (where applicable) evidence based dental care at a fair price. You have the right to information relating to your dental healthcare care and related industry regulations, professional code of conduct and related best practices. A charter of healthcare rights (available in 17 languages) is provided at the front desk which you may read (English version - wall mounted at the front-desk) or request a copy for your future reference. This practice including the waiting area and each of the surgeries are fully equipped with the state-of-the-art patient
education and treatment planning systems. Please feel free to ask your dentist to demonstrate applicable dental procedures using the in-house X-PLAIN software tool and other available Patient Education Systems while diagnosing and planning your treatment including providing you with a proper treatment plan and answering your queries. The dentists are required to continue to communicate with you (the patient) throughout the progress of your diagnosis and treatment and have a responsibility to ensure that what is being communicated is both understood and consented by you (the patient) including for any post-operative care, reviews and recall procedures. You may stop your dentist at any time to seek clarification(s) before continuing. You may also refuse any further treatment if you feel uncomfortable, dissatisfied or coerced in any way and request your treatment transferred to another dentist within this practice or alternatively seek a second opinion before proceeding with your proposed treatment. You have the right to enquire about our infection control protocols and procedures currently in place and discuss your concerns with the management at any time. You have the right to reschedule or cancel your appointments as per the practice cancellation policy displayed on the notice board. You have the right to lodge a complaint against the dental provider or any another staff member to the practice manager verbally or in writing. Our initial complaint response time is within 48 hours with a scope of a full and final resolution within 28 days (if matter handled by the practice) from the date of your complaint lodgement unless the matter is referred by the dentist to DCP (ADA).

We believe that, within the purview and the guidelines of our governing professional bodies, our patients are the best judge of our service quality having the best ideas for our service improvements. A complaint lodgement register is maintained at the Front-Desk to understand and resolve all your problems and concerns comprehensively and systematically. For your general feedback and suggestions, a separate diary is maintained at the front-desk for patient’s remarks and to add your own for our ongoing staff learning and training.

1. PLEASE READ CAREFULLY ALL INFORMATION CONTAINED IN THIS DOCUMENT BEFORE COMPLETING, SIGNING AND SUBMITTING IT TO THE FRONT-DESK OPERATOR/DENTIST. PLEASE SEEK CLARIFICATIONS WHERE IN DOUBT.
2. TO ENABLE US TO PROVIDE YOU WITH A CONTINUED AND TIMELY CARE AND MAINTAIN OUR SERVICE QUALITY, IT IS IMPERATIVE THAT YOU KEEP YOUR RECORDS KEPT WITH US ACCURATE, COMPLETE AND UP-TO-DATE AT ALL TIMES. YOU MAY FORMALLY INFORM US VIA EMAIL / FAX / POST UPDATING ON ANY CHANGES IN YOUR HEALTH CONDITIONS AND MEDICATIONS AND PRIOR TO RELOCATING TO A NEW ADDRESS.
3. DIGITAL SURVEILLANCE CAMERAS AND MONITORED ALARM SYSTEMS ARE IN OPERATION ON THIS PREMISES FOR PATIENT, STAFF AND ASSETS PROTECTION AND SECURITY. APPROVED FIRST AID & OTHER EMERGENCY SAFETY PROVISIONS ALONG WITH A RECOVERY ROOM ARE AVAILABLE AT THIS PRACTICE FOR YOUR PERSONLIZED CARE AND COMFORT.

THANK YOU FOR YOUR ATTENTION