New Patients

Personal Information

Home Address

Referral Information

Consent for Services

• I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetic and other medication as indicated and I will assume responsibility for the fees associated with those procedures.
• I understand that the practice requires at least 24 hours notice if I need to cancel my scheduled appointment and that a cancellation fee may be incurred if I fail to do so.
• I hereby authorise the dentist or the designated team to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.
• I am aware that payment is required on the day of treatment.
• We provide a courtesy to our patients a preventative recall program that offers a call service if you have not been to the practice in 6 months.