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New Patient Form




    YesNo


    If No(details):

    HOSPITAL:

    YesNo

    DENTAL:

    YesNo

    FUND:




    Please tick if your child has ever been diagnosed with any of the following?

    Heart murmur/surgeryAsthmaCancerEpilepsyDiabetesSensory impairmentLiver disease (hepatitis)Kidney diseaseAutism/Asperger’s SyndromeChildhood arthritisGastrointestinal diseasesLearning or developmental delayBleeding disordersHIV/AIDSCreutzfeldt-Jacob DiseaseCleft /clefting conditionLow/very low birthweightMalignant hyperthermia





    YesNo

    YesNo







    Routine examinationReferral from dentistPast difficult experienceDental traumaDental pain/infectionOther


    The information provided in this document is true and correct to the best of my knowledge at the time of signing and I am also aware of Newcastle Paediatric Dental Service’s Privacy Policy.



    In order to provide your child with the highest standard of specialist dental care, this practice is required to collect personal information from you. This information covers basic details such as your child’s name, address and telephone number but it is also necessary to obtain details regarding their general health and past medical and surgical events. Without this general health picture the dentist is unable to plan your care properly.


    Naturally, some information is of a personal nature and some of it might be regarded as “sensitive” and not the sort of information that you wish to be unnecessarily disclosed to others.



    We value the need to safeguard this information and, in accordance with the principles laid down in privacy legislation and the guidelines issued by the Australian Dental Association, we would like to assure you that:


    • This information will only be used by the treating Practitioner 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 we will provide this access without undue delay. This access might be by inspection of your records at the time of your appointment or by special access or copying information

    • There will be no charge for requesting this information but there may be fees levied just to cover the costs associated with the processing of this request for copying information

    • We will take all reasonable steps to ensure at all times that the details we keep about you are accurate, complete and up-to-date

    • We will take all reasonable steps to protect this information from misuse or loss and from unauthorised access, modification or disclosure

    • Our staff are trained to respect these principles at all times



    If you have any questions regarding the information we collect from you and hold in your records at this
    practice, please do not hesitate to ask us. We are acting in your interest at all times.


    The information provided in this document is true and correct to the best of my knowledge at the time of signing and I am also aware of Newcastle Paediatric Dental Service’s Privacy Policy.













    YesNo


    YesNo


    YesNo


    YesNo


    YesNo

    The information provided in this document is true and correct to the best of my knowledge at the time of signing and I am also aware of Newcastle Paediatric Dental Service’s Privacy Policy.


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