Patient Information

Gender*

Male Female Non Binary

Title*

Dr Mr Mrs Ms Miss Mst

Family Name*

First Name*

Preferred Name*

Date of Birth*

Address*

Postcode*

Suburb*

Email Address*

Mobile*

Do you have a Medicare?*

Yes

Medicare Number*

Ref# *

Medicare Expiry date (MM/YYYY)*

* please note there may be an additional charge if no Medicare details are provided.

Family Dentist Full Name*

Last Dental Check-Up*

Do you have a referral?*

Yes No

How did you hear about Beachside Orthodontics?*

Google Facebook/Instagram Dentist Other

If other, please specify

Orthodontic concerns*

Have other family members had treatment with us?*

Yes No

If yes, who?

Have you ever had any of the following?

Have you had an accident involving your teeth or jaws?*

Yes No

If yes, please give details

If under 18 years, please enter details of the person financially responsible for this patient

If yes, please give details

Yes No

Emergency contact details

Name*

Phone*

Relationship to Patient

Treatment preference

Attach records or referral

Accepted file types: jpg, gif, png, pdf (up to 5 files only; max file size 10MB).

Browse to attach files

Payment preference options

Pay in full Payment Plan

* Average full treatment fee is $10100 and can vary depending on age of patient, complexity and if multiple devices are needed.
* Average deposit is 28%

Health Information & Our Privacy Policy

In accordance with the Privacy Act 1988 and the Health Records and Information Privacy Act 2002

Beachside Orthodontics respects your right to privacy. We realise that it is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our practice and to whom this information might be disclosed.

The policy of our practice is to follow these procedures:

The information collected on this form will be used for the purpose of providing treatment to you. Personal information such as your name, address and health insurance details will be used for the purpose of addressing accounts to you, as well as processing payments and writing to you about any issues affecting your treatment.
We may disclose your health information to other health care professionals, or require it from them if in our judgement, that is necessary in the context of your treatment. In that event, disclosure of your personal details will be minimised wherever possible.
We may also use parts of your health information for research purposes, in study groups or at seminars as this may provide benefit to other patients. Should that happen, your personal identity will not be disclosed without your consent to do so.
Your patient history, treatment records, x-rays and any other material relevant to your treatment will be kept here. You may inspect or request copies of your treatment records at any time, or seek an explanation from the dentist. If you want copies, a fee may apply. If you require an explanation of your records or a written summary, a consultation fee or other charge may apply.
If any of the information we have about you is inaccurate, you may ask us to alter our records accordingly.
Beachside Orthodontics may request to take images for social media; this might be verbal or written consent from the patient or parent/guardian.
Contact information will be used to follow up and inform as necessary; before, during and after treatment.

You can otherwise rest assured that your health information will be treated with the utmost confidentiality. Disclosure will not be made to any person not involved in either your treatment or the administration of this practice, without your prior written consent unless we are required to do so by law. If you have any queries or concerns about our handling of your health information, please do not hesitate to raise these concerns with our practice.

I acknowledge that I have read and understood the Privacy Policy and consent to the use of my/the patient’s health information.

Date*

Client over 18 to sign OR Responsible Party to sign

For further information about how we use your data, please see our privacy policy.

New patient form

Patient Information

Gender*

Title*

Do you have a Medicare?*

Do you have a referral?*

How did you hear about Beachside Orthodontics?*

Have other family members had treatment with us?*

Have you ever had any of the following?

Have you had an accident involving your teeth or jaws?*

If under 18 years, please enter details of the person financially responsible for this patient

If yes, please give details

Parent 1 Title*

Parent 2 Title*

Emergency contact details

Treatment preference

How soon do you want to start?

Are all of your adult teeth through?

Attach records or referral

Payment preference options

Health Information & Our Privacy Policy

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