Covid-19 SafePlease enable JavaScript in your browser to complete this form.1Personal Information2Recent Travel History3Recent Medical History4Updated Policies & ProceduresPersonal InformationName *FirstMiddleLastDate of Birth *Address *Address Line 1CityState / Province / RegionPostal CodeNextHave you done any travel in the last Fortnight (14 Days)? *YesNoWhere did you travel? *Date of Travel (Departed from Home) *Date of Travel (Returned Home) *Have you been in contact with anyone who has traveled in the last Fortnight (14 Days)? *YesNoWhere did they travel? *Date of Travel (Departed from Home) *Date of Travel (Returned Home) *Relationship to Traveler *PreviousNextHave you had any of the following Symptoms in the last Fortnight (14 Days)? *ChillsFeverDry CoughSweatsAches & PainsSore ThroatDiarrheaHeadacheLoss of Taste or SmellTired / Lethargic None of the AboveWhen did Symptoms first present themselves? *Have the Sympotoms Ceased? *YesNoUnsureWhen did Symptoms Cease? *Have you been in contact with anyone who had any of the following Symptoms in the last Fortnight (14 Days)? *ChillsFeverDry CoughSweatsAches & PainsSore ThroatDiarrheaHeadacheLoss of Taste or SmellTired / Lethargic None of the AboveWhen did Symptoms first present themselves? *When did Symptoms Cease? *Relationship to Person *PreviousNextAppointments & Arrivals *AcceptTo 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 *AcceptHand 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 *AcceptIt 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 *AcceptIn 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 *FirstLastI here by agree and acknowledge all of the information provided within this form is true and accurate.Date / Time *PreviousPhoneSubmit
