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Updated Information


Watagan Dental Patient Update Form

Please complete this form to help us provide the best care for you. If the patient is unable to complete this form, a next of kin or legal guardian may fill it out on their behalf.


Patient Information

Birthday
Month
Day
Year
Has your phone number changed?
Yes
No
Has your email address changed?
Yes
No
Has your address changed in the last 12 months?
Yes
No
Have you changed healthfunds?
Yes
No

Medical Screening

Are there any changes to your medical history (new medications, allergies or conditions?)
Yes
No
Do you have any new doctors or specialists we should know about?
Yes
No

Patient Photography Consent

In certain circumstances, photography may be taken as part of your consultation to monitor and assist in managing conditions. These images will form part of your medical record.

I consent to photographs being taken, stored in my dental record.
Yes
No
I consent to my photographs being de-identified and used for medical education, teaching, or research purposes, including publication in medical journals.
Yes
No
I consent to my de-identified photographs being used for website or publicity purposes.
Yes
No

Consent For The Use Of An Electronic Scribe

At Watagan Dental, we strive to provide you with exceptional care and focus during your visits. To enhance the quality of our consultations, we use a secure note-taking tool to accurately document our discussions and the outcomes of your appointments for our dental record. No recordings are kept of these conversations.

I consent to the use of an electronic scribe to be used during my appointment.
Yes
No

Appointment Attendance Policy:

To ensure all patients have an opportunity to get the treatment they need we require 24 hours notice of appointment cancellation. Canceling with less notice than this will incur a booking fee for all future appointments. Please see our cancellation policy at: https://www.watagandental.com.au/services/cancellation-policy

Signature

I confirm that the information provided is accurate to the best of my knowledge. If completed by a next of kin or legal guardian, I confirm my authority to provide this information on behalf of the patient.

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Date
Month
Day
Year
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