Registration Review (EXISTING patients only)

In order to provide the best and safest dental treatment, it is important that we have your contact details and know of all medical problems which may affect your treatment

First name

Last name

Date of Birth(dd/mm/yyyy)

Please indicate if you think your name has changed since you last visited us?
Yes No

Please indicate below if you are an existing patient of MDental?
Yes No

Please indicate below if you think you have changed your address since your last visit. If you answer Yes, could you please record your new address in the space provided alongside?
Yes No New Address

Please let us know if you have changed your phone number or mobile number or email address since your last visit. If yes, could you please record your new details in the spaces provided below? It is really important that we have accurate contact details to allow communication.

Work phone

Home phone

Mobile

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 the use of my records, xrays and photographs for scientific presentation in conferences/print/web publications without compromise of my identitity. Finally, I alsoconsent to MDental's financial and cancellation policies above 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 existing patient medical history details form.