New Patient Form


Thank you for taking the time to fill out this medical history. This enables us to give you the best possible care.

The team at Coastal Dental Care would like to welcome you and thank you for choosing us as your dental provider. In aiming to provide the highest level of dental care, we ask for your co-operation and understanding in regards to the following:

ACCOUNTS – All accounts are to be paid at the time of your appointment. We accept cash, EFTPOS, MasterCard, and Visa. If you are in a health fund we are able to process your claim through our HICAPS system on the day of your appointment. If you are unable to pay the full account at the time of your appointment, please notify the receptionist prior to your appointment and adjustments may be made to the dental treatment you receive on the day. In the event where your overdue account is referred to a collection agency and/or law firm, you will be liable for all costs which would be incurred as if the debt is collected in full.

CANCELLATIONS – Our practice requires a minimum of 24hrs notice for cancellations. This allows us to allocate that time to other patients who may require urgent treatment. Should insufficient notice be given a minimum cancellation fee of $50 (per ½ hr appointment) may apply. As a courtesy we endeavour to confirm all patient appointments the day before.

ARRIVING LATE – If you are aware in advance that you may be late to your appointment please notify us as soon as possible as we may be able to reorganise our day so as not to inconvenience other patients. Where this is not possible we may need to limit your treatment to the amount of time remaining or reschedule your appointment.

MOBILE PHONES – We ask that your mobile phone remains switched off at all times whilst in the treatment rooms.

FOOTWEAR – This is a surgical environment and as such Health and Safety Regulations require footwear to be worn at all times within our practice.

CONSENT – All contact information provided may be used to reach you in regards to treatment and appointments.

Privacy Statement

In order to provide you with the highest standard of care, this practice is required to collect personal information from you. This may involve speaking to other medical and dental professionals who are managing your overall health or speaking to other health professionals for opinions in assisting us to manage your dental health. Some of this information is of personal nature and we value the need to safeguard it. In accordance with the principles laid down in the privacy legislation and the guidelines issued by the Australian Dental Association we would like to assure you that:

  • The treating dentist will only use the information in order to deliver your care to the highest standards.
  • It will not be disclosed to those not associated with your treatment, without your express consent.
  • You may seek access to the information held about you and will provide this without any delay. This access might be by
  • inspection of your dental records at the time of appointment or by special access.
  • There will be no charge made for requesting this information but there may be fees levied just to cover the costs of
  • associated with the processing of this request or the copying of information.
  • We will take reasonable steps to ensure that at all times the details we keep about you are accurate, complete and up to date
  • We will take reasonable steps to protect this information from misuse or loss and from unauthorized access, modification or
  • Our staff are trained to respect these principles at all time.

If you have any questions regarding the information we collect from you and hold in your records, please do not hesitate to ask. View our privacy policy.

We look forward to continuing to provide you and your family with optimal dental care now and in the future.

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