Dental Patient Form Page 3
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1
2
3Dr Sharon Marinucci
Dr John Wills
Dr Ruth Mansell
Dina Jeffery
BDS / BSci Dent (Hons)
BDS
BDS / MJDF
Dental Therapist
Dr Ruth Drakes
Dr Margaret Kleinig
Dr Emma Codrington
Wendy Summerill
BDS
BDSc QLD
BMedSci / BDent
Dental Therapist
Dr Cathy Do
Dr Philippa McCarron
Dr David Armstrong
Bernadette Basset
BD
BDS
BDC MdSc
FRACDS
Dental Therapist
(Ortho)
(Ortho) PhD
Dr Devendra Rao
Dr Benjamin Mansell
Sue McDonald
Ms Susan Waldorf
BDS
BDS / MJDF
Dental Prosthetist
Oral Health Therapist
Dental Corporation Pty Ltd abn: 92 124 730 874
Terms of Acceptance
1/. All dental treatment is carried out using up to date techniques, equipment and materials.
All equipment is either disposable or sterilised using an autoclave which is validated daily for
optimal e ciency.
2/. It is the policy of this practice to take diagnostic radiographs (x-rays) at the rst examination
and speci c radiographs (x-rays) as required before certain procedures. If you do not want
routine radiographs (x-rays) please sign here __________________________________________
3/. A current periapical radiograph (x-ray) will be taken prior to any extraction. This is for your
protection as well as for ours.
4/. Any treatment required will be provided with the patients informed consent after all risks
associated with the treatment are outlined.
5/. All information on this form is considered con dential and is necessary to ensure that the best
possible treatment can be provided.
6/. Each appointment made is a contract between Fresh Dental Care and the patient. All appointments
cancelled with less than 24 hours notice will incur a $48.00 cancellation fee to help cover costs. Any
appointment not attended will incur a $69.00 fee.
7/. An estimate of fees for treatment should be outlined prior to treatment being provided. If you are
not sure of estimated fees, you need to let us know.
8/. All fees incurred per appointment must be settled at the completion of that appointment.
9/. Dishonored cheques will incur a $48.00 dishonor fee.
10/. Should any account for any reason become outstanding, then the patient, or person responsible
for accounts, will be responsible for all debt collection charges incurred.
I _____________________________________________________ con rm that the medical history
provided is a true indication of my health at this time, I also agree to the terms set out above.
Signed __________________________________________ Date______/______/__________
PO Box19
252 Harbour Drive
46 Bonville Street
1 Princess Street
Grafton NSW 2460
Coffs Harbour NSW 2450
Urunga NSW 2455
Macksville NSW 2447
p
(02) 6643 2225
p
(02) 6651 1350
p
(02) 6655 5800
p
(02) 6568 1335
f
(02) 6643 5544
f
(02) 6651 1973
f
(02) 6655 5801
f
(02) 6568 1222
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