Skygate Dental Medical History Form

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.