Pre Treatment Form

Full Name*:

Have you had any of the following?

We would like to keep in touch about news and events at the practice, special offers and dental advice via our quarterly e-newsletter, Smile-mail.

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.

Due to Privacy & Confidentiality laws, we are prohibited from disclosing any information regarding your personal details and/or dental treatment unless you have personally signed a request form.

Full payment is required at the time of consultation. In the event that a bad debt is established the responsible party will be held accountable for the total account balance plus any fees incurred in collection of the debt.

We accept visa and mastercard, personal cheque, eftpos and cash. Third party payment plans are also available via GEM Visa.

A cancellation fee will apply if less than 48 hours notice is given.