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1
Personal Information
2
Recent Travel History
3
Recent Medical History
4
Updated Policies & Procedures
Personal Information
Name
*
First
Middle
Last
Date of Birth
*
Address
*
Address Line 1
City
State / Province / Region
Postal Code
Next
Have you done any travel (Including Inter-State) in the last Fortnight (14 Days)?
*
Yes
No
Where did you travel?
*
Date of Travel (Departed Home)
*
MM
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1925
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1921
1920
Date of Travel (Returned Home)
*
MM
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7
8
9
10
11
12
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DD
1
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YYYY
2021
2020
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2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
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1991
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1985
1984
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1981
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1972
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1928
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1925
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1923
1922
1921
1920
Have you been in contact with anyone who has traveled (including Inter-State) in the last Fortnight (14 Days)?
*
Yes
No
Where did they travel?
*
Date of Travel (Departed from Home)
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
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13
14
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18
19
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21
22
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29
30
31
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YYYY
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
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1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Date of Travel (Returned from Home) (copy)
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
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8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Relationship to Traveler
*
Previous
Next
Have you had any of the following Symptoms in the last Fortnight (14 Days)?
*
Chills
Fever
Dry Cough
Sweats
Aches & Pains
Sore Throat
Diarrhea
Headache
Loss of Taste or Smell
Tired / Lethargic
None of the Above
When did Symptoms first present themselves?
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
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11
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13
14
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16
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18
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21
22
23
24
25
26
27
28
29
30
31
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YYYY
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Have the Sympotoms Ceased?
*
Yes
No
Unsure
When did Symptoms Cease?
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Have you been in contact with anyone who had any of the following Symptoms in the last Fortnight (14 Days)?
*
Chills
Fever
Dry Cough
Sweats
Aches & Pains
Sore Throat
Diarrhea
Headache
Loss of Taste or Smell
Tired / Lethargic
None of the Above
When did Symptoms first present themselves?
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
When did Symptoms Cease?
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
YYYY
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Relationship to Person
*
Previous
Next
Appointments & Arrivals
*
Accept
To help ensure we are maintaining a safe, Covid-19 free environment here at Skygate Dental. We are asking all patients to come alone to their appointments, when possible. If it is not possible to arrive alone, we ask where possible for accompanying individuals remain in their vehicles, during the appointment. If you require mobility assistance, are nervous to be seen alone, and / or a minor, please advise us while booking your appointment or prior to arriving.
Hygiene
*
Accept
Hand and Oral Hygiene are paramount in assisting to stop the spread of Covid-19. Skygate Dental is ensuring best practices are in place at all times. All arriving patients will be greeted with Hospital Grade Hand sanitizer prior to entering the clinic. All patients will be required to do a pre-op rinse prior to treatment commencing. All treatment rooms and the lobby are thoroughly sterilized between each patient.
Social Distancing
*
Accept
It is important to maintain social distancing during this time to assist in mitigating the spread of Covid-19. Skygate Dental is committed to providing an environment which supports appropriate social distancing. In order to do so, between arrivals, appointment completions, and patients bookings, we ask for your patience as there may be minor delays between arriving, admitting, and discharging as we ensure the rooms are clear in order to be able to maintain social distancing.
Terms & Conditions
*
Accept
In order to provide you with the highest standard of dental care, this practice is required to collect personal information from you. This information covers basic details such as your name, address and telephone number but it is also necessary for the dentist to obtain from you details regarding your general health and past medical and surgical events. Without this general health picture, the treating dentist is unable to plan your care properly. Naturally, some of this information is of a personal nature and some of it might be regarded as ‘sensitive’ and not the sort of information that you would wish to be unnecessarily disclosed to others.
We value the need to safeguard this information and, in accordance with the principles laid down in privacy legislation and the guidelines issued by the Australian Dental Association, we would like to assure you that:
This information will only be used by the treating dentist in order to deliver your care to the highest standards.
It will not be disclosed to those not associated with your treatment without your consent except as provided under the legislation and where we consider you would have a reasonable expectation of us to provide such information.
You may seek access to the information held about you and we will provide this access without undue delay. This access might be by inspection of your dental records at the time of appointment or by special access or copying of information at other times.
There will be no charge made for requesting this information but there may be fees levied just to cover the costs associated with the processing of this request or the copying of information.
We will take reasonable steps to ensure at all times that the details we keep about you are accurate, complete and up to date.
We will take reasonable steps to protect this information from misuse or loss and from unauthorized access, modification or disclosure.
Our staff are trained to respect these principles at all times.
PAYMENT POLICY
I verify that all details I have provided in the medical history form on the reverse is true and accurate. I confirm that by accepting a an appointment and / or treatment there is likely a to a related fee.
I indemnify RCMP Dental Group Pty. Ltd. from and against all costs and disbursement incurred in recovering overdue invoices (including but not limited to legal costs, collection agency costs, internal administration costs and bank dishonor fees).
I understand that interest on overdue invoices shall accrue daily from the date of unpaid treatment to the date of payment at a rate of three per cent (4.0%) per calendar month.
Name of Patient or Guardian
*
First
Last
I here by agree and acknowledge all of the information provided within this form is true and accurate.
Date / Time
*
MM
1
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5
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9
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DD
1
2
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13
14
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16
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30
31
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YYYY
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
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1991
1990
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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