New patient registration

New patient registrationThank you for choosing MDental for your dental needs. This form is an important source of information for us.
Please take time to complete it accurately. Indicate your acceptance of check boxes by clicking within them.

First name

Last name

Number and Street

Suburb

City

Post Code

Work phone

Home phone

Mobile

Date of Birth(dd/mm/yyyy)

Occupation

When did you last see a dentist ?

What was the name of your last dentist?

How did you hear of MDental ?
Friend Newspaper Corporate Plan company Website Facebook If Others, please mention..

If you are under 16, please advise us of your parent/guardian's name

Please give us your parent/guardian's address, if applicable

Do you have dental insurance ?
Yes No

Do you smoke?
Yes No

MDental does not provide amalgam (silver) fillings. Are you happy to accept this?
Yes No

If you have indicated 'No' to the above question, please contact reception for referral to other dentists who use amalgam.

Although rare, accidental injury to staff can occur during handling of used instruments. If this happens during the course of your treatment, MDental requires patient and staff member to undertake a blood-test. Do you agree to a confidential-blood test ?
Yes No I wish to discuss this with the dentist.

If you have indicated 'No' to the above question, please advise Reception staff immediately to clarify this.

Financial Policy

MDental's financial policy is to request payment for all treatment on the day of treatment. Credit arrangements, if any or arrangements for receiving accounts, must be made in advance. Overdue accounts will reluctantly be transferred to a debt collection agency and will incur interest at 10% per annum. The cost of debt, interest and recovery will be passed on to the account holder.

Cancellation Policy

M Dental reserves the right to charge a cancellation fee for appointments canceled at less than 48 hours notice.

General consent

I confirm that the information provided above is true and correct. I provide general consent for my treatment by the dentists at MDental. I also consent to the use of my records for communication. I further consent to use of my records, xrays and photographs for scientific presentation in conferences/print/web publications without compromise of my identity. I also further consent to MDental's financial and cancellation policies as well.

Patient/Parent/Guardian's name

Note: Upon clicking Next button below, an image shown below gets displayed PLEASE CLICK OK to get directed to new patient medical history details form.