New Patient Registration Form

Please complete all sections. This information helps us provide you with the best possible dental care.

Step 1 of 2

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Patient Details

Title

Date of Birth(Required)

DD slash MM slash YYYY

First Name(Required)

Surname(Required)

Middle Name

Preferred Name

Occupation

Home Address(Required)

Suburb(Required)

Post Code(Required)

Mobile(Required)

E-Mail(Required)

Do you belong to a private health fund?

Yes

Which Fund?

Membership Number

Ref No.

Referral Source

Dentist

Flyer

Online

Other

If Other, please specify

PLEASE ANSWER ALL OF THE FOLLOWING QUESTIONS

(In order to provide you with the best dental care, we require a sound knowledge of your general health)

1. Have you ever had any type of heart disease, heart murmur, or rheumatic fever?

Yes

Please specify (1)

2. Have you ever had heart valve or a pacemaker?

Yes

Please specify (2)

3. Have you ever had a stroke?

Yes

4. Are you allergic to any tablets or medicines?

Yes

If yes, please specify your allergies:

5. Have you ever had fits or epilepsy?

Yes

6. Do you have diabetes?

Type I

Type II

7. Do you smoke?

Yes

Number per day

8. Have you ever had Tuberculosis, Asthma, or any other Lung Disease?

Yes

Please specify (8)

9. Have you ever undergone a test for HIV (the AIDS virus)?

Yes

9b. Do you have any reason to believe you may have been exposed to the virus?

Yes

10. Please list any medications that you have taken in the last month

11. Do you or any members of your family have a history of Creutzfeldt-Jacob Disease (CJD)?

Yes

12. Do you have any bleeding problems or blood disorders?

Yes

Please specify (12)

13. Women only: Are you pregnant?

Yes

Number of months

14. Do you have an infectious disease or liver problem?

Yes

Please specify (14)

15. Do you have any Joint Problems, Arthritis or Joint Replacement Surgery?

Yes

Please specify (15)

16. Do you have any other medical problems?

Yes

If yes, please specify your medical problems:

Name of your General Dentist

Phone number of your General Dentist

Name and phone number of a person to contact in case of an emergency

Name

Phone Number

Consent

I confirm that the personal information I have provided is true, complete, and accurate to the best of my knowledge.

Consent

I confirm that I have disclosed all relevant medical conditions, medications, allergies, and other health information that may affect my or my dependant's dental treatment. I understand that it is my responsibility to notify the practice of any changes to my or my dependant's health or personal details.

Consent

I have read, understood, and agree to the practice's Payment Policy, including fees, payment terms, and cancellation policy.

Your Health Information - Privacy Consent Form

Our practice, Dr Boris Cherkasski trading as MDS Manningham Dental Specialists, respects your privacy and is committed to protecting your personal information in accordance with the Australian Privacy Principles (APPs). Our Privacy Policy is available on request.

We collect personal and health information to provide you with safe and appropriate dental care. This may include your contact details, medical and dental history, health insurance information, and other information required to manage your treatment, appointments, accounts, and payments.

Where necessary for your care, we may collect information from or share information with other healthcare providers involved in your treatment. If you choose not to provide information relevant to your care, we may be unable to provide appropriate treatment or the services you require.

Your clinical records, including medical history, treatment notes, radiographs, photographs, scans, and other relevant records, will be securely stored by the practice. In some cases, our electronic records may be securely stored using cloud-based service providers located outside Australia. Any overseas disclosure will comply with our obligations under the Australian Privacy Principles.

To improve the accuracy and efficiency of our clinical records, we may use secure Artificial Intelligence (AI) software to assist in recording and summarising clinical conversations during your appointment. AI-generated documentation is used solely to support your treating clinician, who reviews and verifies all records before they become part of your clinical file. Your information remains confidential and is handled in accordance with applicable privacy laws and our Privacy Policy.

You may request access to, or correction of, your personal information, or make a privacy complaint, as outlined in our Privacy Policy. If you have any questions or concerns regarding your privacy, please contact our Privacy Officer during business hours.

By signing below, you acknowledge that you have read and understood this Privacy Consent and consent to the collection, use, storage, and disclosure of your personal and health information as described above, including the use of AI-assisted clinical documentation.

Patient Name:

Parent/Guardian Name (if patient is a minor):

Consent

I acknowledge that I have read and understood this Privacy Consent and consent to the collection, use, storage, and disclosure of my or my dependant's personal and health information as described above, including the use of AI-assisted clinical documentation.

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New Patient Registration