Date Of Birth
Person responsible for this account
Private Health Insurance
Emergency contact name
Emergency contact number
Emergency contact relationship to patient
Please complete next section if you are under 18:
Relationship to patient
Medical Practitioner’s name and suburb
Have you had, or do you currently have, any of the following (please circle):
Do you take bone strengthening drugs?.
Rheumatic fever/Heart valve
Asthma/other respiratory problems
Do you have any allergies?
Blood thinning medication (e.g. Warfarin)
If yes, details:
Please list all medicines you’re currently taking including vitamins and herbal medicines.
Do you have any other medical conditions? Please list
All payment is required on the day of service. Payments of cash, EFTPOS and credit card are accepted.
” Please kindly note that when you book your appointment with us, especially an emergency one, there is a cancelation policy applicable. Cancelation/No show policy:
This cancelation policy is set to avoid and prevent leaving out other patients with dental pain to have the limited daily emergency slot. Please be considerate towards our other emergency patients, our staff and the practice’s time.
NEW PATIENT: If you are a NEW PATIENT and cancel your emergency appointment within 72 hours, the cancelation fee may be applicable.
If you have been consulted with us before, or if you are in the middle of your treatment and cancel your non-emergency appointment within 72 hours, the cancelation fee shall be defined as a percentage of your session’s fees. You might be notified by an automated email and the practice’s software automatically will send you an invoice according to your booking reason/s. Please get in touch with us immediately after receiving the invoice. We are here to help you out planning for your missed appointments.
To avoid disappointments, please make your appointment wisely. Do not double book yourself in another practice especially after you requested an emergency appointment with us.
We have been working hard to accommodate every emergency patient in our limited dedicated daily slot. We also plan according to this to ask our lovely staff stay longer, have shorter breaks and work under pressure. You will always see us smiling, welcoming and caring. We thrive to go above and beyond to make everyone happy and satisfied with our services. Please help us to continue doing the right thing by being good and considerate to us.
Thank you. “
All information provided is treated as confidential and this is a medico-legal document.
Please ensure that you read and understand the form before signing.
If you have any queries or concerns please discuss with your endodontist.
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