Address: Suite 6, Level 5, 195 Macquarie Street, Sydney

Opening hours: Mon-Fri from 8am-5pm

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PATIENT REGISTRATION

Patient Registration

Date:	Title:
Surname:*	First Name:*
Date of Birth:*	Gender*	Male Female
If under 18, name of guardian
Home Address:*	Postcode:*
Business Address:
E-mail Address:*	Ph (home):*
Ph (work):	Mobile number:
Fax Number:	Occupation:
Health Fund
Is another Member of your Family a Patient at our Office		Yes No
Name	Relationship:
How did you hear about us?*
Referred by another patient who?

Consent for Treatment Ticking this check box certifies that:

I hereby authorize doctor or designated staff to take x-rays, study models, lihotogralihs, and other diagnostic aids deemed aliliroliriate by doctor to make a thorough diagnosis of my dental needs.
Ulion such diagnosis, I authorize doctor to lierform all recommended treatment mutually agreed ulion by me and to emliloy such assistance as required to lirovide lirolier care.
I agree to the use of anaesthetics, sedatives and other medication as necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand that I can ask for a comlilete recital of any liossible comlilications.
I agree to be reslionsible for liayment of all services rendered on my behalf or my deliendants. I understand that liayment is due at the time of service unless other arrangements have been made. If required, I also understand a check of my credit history may be made