Hadfield Dental Group

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* Please be sure to fill out ALL areas of registration form, especially underlined areas.

Patient Information

Patient’s last name:

First:

Middle:

Title: (please circle)

Mr. Mrs Ms.

Miss. Dr

Is this your legal name?

If not, what is your legal name?

(Former name):

Birth date:

Age:

Sex:

Yes

/ /

Street address:

Mobile Phone no:

Home phone no:

P.O. box:

Suburb:

State:

Post Code:

Email Address:

Occupation:

Employer:

Employer phone no.:

Work address:

( )

Chose clinic because/Referred to clinic by (please check one box or comment):

Family

Friend

Close to home/work

Internet

Other?

____________________________

Other family members seen here:

Insurance Information

Do you have Private Health Insurance? Y N Insurance Company:

(Please give your insurance card to the receptionist.)

Person responsible for bill:

Birth date:

Address (if different):

Contact phone no.:

/ /

( )

Medical Questions

Rheumatic Fever Heart Conditions High Blood Pressure Stroke Asthma Diabetes

Thyroid Problems Tuberculosis Epilepsy Bone Disorders or Diseases Fainting/Dizzy Spells Excessive Bleeding

Hepatitis A/B/C/E A.I.D.S/HIV Virus Would you like to discuss these questions in private with the dentist? Y N

Family History of Heart Disease, Diabetes or Stroke? Y N

Are you allergic to any Medications: i.e. (penicillin/aspirin)? Y N

Do you have any allergies? Y N

Are you taking any medications? (Please specify) Y N

Have you ever had an operation? (Please specify) Y N

Do you have: an artificial hip, heart valve or any other prosthetic implant? Y N

Have you ever had Botox? Y N

Have you ever had Dermal Filler? Y N

Females: Are you pregnant? Y N Comments:

Any other medical conditions:

Are you a smoker? Y N If yes, how many a day?

Name/address/phone number of Medical Practitioner:

In Case Of Emergency

Name of local friend or relative :

Relationship to patient:

Home phone no.:

Work phone no.:

( )

The above information is true to the best of my knowledge, and I understand that failure to make a full disclosure might place ME at undue medical risk. I understand that notes, radiographs (x-rays) or models relating to my treatment may need to be sent to other dental practitioners to aid them in my treatment and consent to this. I also give my permission for the practice to use the above contact details to send me appointment and check up reminders.

I authorize my insurance benefits to be paid directly to the Provider. I understand that I am financially responsible for any balance. I also authorize Hadfield Dental Group or insurance company to release any information required to process my claims.

I understand that I will be responsible for any debt collection fees that might incur due to my lack of finalizing my account by the requested date.

Patient/Guardian Signature:

Date:

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Fail to attend / Late cancellation policy

Hadfield Dental Group aims to treat all patients fairly at all times. A significant amount of valuable clinical time is wasted when appointment are not attended. Patients who fail to attend their appointments or who a cancel an appointment with insufficient notice waste clinical time that could be used for treatment of other patients.

To avoid the cost of failed or late cancelled appointments being passed onto the rest of our patients, we will charge for multiple missed or short notice cancellation of appointments.

We understand that on occasion, life throws up all sorts of situations that prevent one from being able to attend an appointment or even contact to advise that the appointment will not be attended. As these situations are unavoidable they are not the sort of failed appointments that this policy aims to address.

Cancelled appointments

Cancelled appointments will not incur any charge when cancelled with 24 hours or more notice. If it is not possible to keep an appointment please let us know as soon as possible so we can offer the appointment to someone else. If you are unsure whether you can make it to the appointment, please contact us to discuss the matter rather than leaving it to the last minute.

Fail to attend and short notice cancellation of appointments

Failing to attend or cancelling within 24 hours two times within a 12 month period will result in a fee being charged unless there are exceptional circumstances. Patients will be informed verbally and/or in writing and it will be recorded in the patient records. If a second appointment is missed in similar circumstances, then it is likely that a fee will be invoiced in the patients account. Fees will be charged at $50 per appointment missed.

No further appointments will be offered until the missed appointment is settled.

Bulk Billed CDBS fail to attend and short notice cancel appointments

We bulk bill appointments under the Child Dental Benefits Scheme to assist eligible families in seeking dental treatment without having to pay up front. Failing to attend or cancelling within 24 hours two times within a 12 month period will result in us not being able to reschedule appointments at the practice under the Child Dental Benefits Scheme. Any reschedule appointments will be considered private and fees will be charged for any future failure to attend or short notice cancels. Patients will be informed verbally and/or in writing and it will be recorded in the patient records.

Appointment timing and arriving late

As with all medical facilities, we aim to see our patients on time but due to the nature of healthcare, this is not always possible. If patients turn up late for their appointments it can put the dentist further behind and result in running late for subsequent appointments. It will be up to the treating dentist as to whether there is enough of the appointment left to provide treatment.

Reminders

Reminders will be sent for those with mobile numbers registered on our system 1 week and another 2 days prior to the appointment. All messages sent by our system our logged if successfully sent. It is your responsibility to check message details to ensure that we are informed of any changes to your mobile number or for the appointment scheduled. Text messages are sent as a courtesy and failure of the system for any reason is not sufficient reason for failing to attend appointments. For patients without a mobile number registered on our system or who have not replied to the text message we will attempt to contact by phone to confirm.

Further information

For clarification on any matter in relation to this policy please contact Dr Fortina Dandas Managing Director of Hadfield Dental Group or Mrs Laura Sanders Practice Manager.

Patient Form