Existing Patient – Patient Profile Update

Welcome to Wholistic Dentistry

Please fill and submit the following form prior to attending your appointment
Patient Profile Update

Wholistic Dentistry

 

PH: (02) 6297 8838

6/2 Rutledge Street

Queanbeyan NSW 2620

www.wholisticdentistry.com.au

[email protected]


Patient Profile Update

System Upgrade


To provide you with the best possible care, we continually review policies, procedures, and systems to ensure they meet clinical safety requirements and align with modern Australian healthcare standards. To support this commitment, we have chosen to strengthen our record management system. This enhancement ensures we continue to exceed current clinical safety, governance, and privacy standards. As part of this update, and in line with our ongoing commitment to evolving with Australian healthcare standards, we require you to complete and sign the acknowledgement form to support this system upgrade.


Patient Identification


Updated Medical History – Private and Confidential

Please answer these questions fully or discuss them with your dentist. Information about your medical history is for your dentist’s use only.

 

Past/Current medical conditions: (please circle)


CONSENT & DECLARATION

 

Privacy & Clinical Records Consent

I understand my dental/medical information will be stored in secure paper and electronic systems. I consent to its use by authorised staff for treatment, administration, and continuity of care. I understand that information may be shared with other healthcare providers as necessary or as required by law. I may request access to, or correction of, my information at any time.


Medical Declaration
I confirm that the information provided above is true and complete to the best of my knowledge. I understand it is my responsibility to inform the dentist of any changes to my medical history.


General Treatment Consent
I consent to routine examinations, X-rays, photographs, and treatment as discussed with my clinician. I understand I will be informed of the risks, benefits, and alternatives before proceeding, and that I may withdraw consent at any time Financial Consent
I understand that payment is required in full on the day of treatment. I acknowledge that this practice does not offer accounts, credit, or payment plans. Fees will be explained before treatment proceeds.


Patient Declaration
I confirm the information I have provided is true and complete. I will inform the practice of any changes to my medical history.


Parent/Guardian Consent (for patients under 18)