Patient History Update

Please fill out the form in full, without leaving anything blank.

I do not agree to be contacted occasionally for promotions

Title *

Please Select

First Name *

Last Name *

Family Name

Preferred Name

Can leave blank

Date of Birth *

DD/MM/YY

Under 18? Please provide details of parent/guardian, who is also responsible for the account. They must be present to consent to treatment at all appointments unless arranged otherwise by the dentist. *

Name, Phone Number, Relationship - or write N/A

Address *

Your full address including post code

Phone *

Mobile Number

Dental Ancillary Cover *

Emergency Contact *

If we cannot contact you, we will contact this person.

If you have attended another dental practice in the last 2 years, please provide details below if you would like us to request the records to be transferred to us. *

Name of Clinic, Suburb - or write NONE

In a few words, what brings you to the dentist today? *

Brief description of why you've made an appointment.

I have had the following minor changes since I last visited *

Change of medications, new medical conditions, pregnant or breastfeeding, etc - or write NONE

Other Things to Note

Please enter anything not included above.

I acknowledge that this represents an accurate update to my previous personal and medical details.

I will read Practice Policy 2020 below and am aware of the clinic policies outlined.

Digital Signature *

YOUR INITIALS, DD/MM/YY

Phone

Waiting Room Etiquette
In the interest of public health and safety, please note the following:
- No food and drink in the waiting area, unless issued by staff for health reasons
- We welcome someone to support you in the waiting room or treatment room if you need it. However,
we cannot mind your children. Please make alternate arrangements before attending our practice.
- No support animals. While guide dogs are welcome in the reception, they cannot accompany you into
the treatment room which is a surgical sterile area.
- No mobile phones. While we understand it is important for you to be contacted, please switch off your
mobile phone in the treatment room. Please silent your phone in the reception room, with particular
attention to music and videos.

If you are ill
We want to see you when you are fit and well. If you have a cold, cough, flu, cold sore – we cannot see you.
Particularly if you cannot breathe through your nose, it is unsafe for us to treat you. If this is the case, please
call to reschedule your appointment.

Payment Policy
A to Z Dental Cannington is a private dental practice with set fees.
All accounts must be settled in full at the end of the scheduled appointment.
Any outstanding debts will accrue interest of 5% per fortnight. To avoid any extra fees we strongly advise that
you settle your account in full, as per our policy.
Please don’t ask for a discount. Our prices are our best prices.
If you are a current Health Concession Card (HCC) holder, there are government dental clinics which may be
more financially appropriate to address your problem. Please ask reception for more details.
We do not accept Medicare Child Dental Benefits Schedule, or DVA Cards, as of January 2020.

Private Health Funds
If you have a private health fund (for example, HBF, BUPA, Medibank, etc.) please ensure you have your valid
card physically present at every appointment, as we cannot process your account without it.
Should you have problems with your private health fund, or you do not have your card with you, you will be
required to settle the account in full and claim your rebate yourself.

Dental Quotes

While quotes (verbal or written) may be given, this is subject to variation once actual treatment has commenced.
If the treatment significantly differs, we will endeavour to ask you how you wish to proceed.

Extensive Treatment
Should you require extensive treatment, we require a 50% deposit before going ahead. The dentist will let you
know if this is the case.

Late Cancellation/Missed Appointments
A to Z Dental reserves the right to charge a late cancellation/missed appointment fee of $50.00.
This fee is charged for one of the following reasons:
1) The patient is late by more than 15 minutes
2) The patient has failed to attend a scheduled appointment
3) The patient has cancelled within 24 hours of their scheduled appointment

25/53 Cecil Ave
Cannington 6107
(08) 9451 1200
contactus@atozdental.com.au

Thursday, 21st November 2024
6:29 am

Monday	10am - 2pm
Tuesday	10am - 2pm
Wednesday	10am - 6pm
Thursday	10am - 6pm
Friday	10am - 2pm
Saturday	9.30am - 1pm (alt)
Sunday	CLOSED
Will be closed: 29/6, 8/7, 13/7, 15/7, 27/7, 10/8, 24/8, 7/9, 21/9-23/9, 5/10, 19/10 Our online booking system is available 24/7 Confirm an appointment now: Click for Online Booking (opens new window)