Patient Update Form - Islington Dental

Do you have Private Health Insurance that covers: Dental Y N Private Hospital Y N

MEDICAL INFORMATION Please TICK Yes [Y] or No [N] to the following questions:

CONSENT FOR TREATMENT

By submitting this form, I hereby authorise the dentist or designated team to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide appropriate care. I agree to the use of anesthetics’, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand I can ask for a complete recital of any possible complications. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made. I authorise that this data may be reviewed by team members of the dental practice.