Quality Dental Care in Adelaide

New Patient Form

Please take time to answer these questions. It will assist us in providing the best care for you.

CONTACT INFORMATION

HEALTHCARE IDENTIFIERS

Do you have a health fund?*

YesNo

PATIENT CONSENT

Please read this form carefully prior to signing

At Burnside Dental practice we collect this information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose and treat dental conditions and ensure we are proactive in your dental care. To enable ongoing care, and in keeping with Privacy Act 1988 and Australian Privacy Principles, we wish to provide you with sufficient information on how your personal information may be used or disclosed and record your consent or restrictions to this consent.

By signing below, you (as a patient/parent/guardian) are consenting to the collection of your personal information, and that it may be used or disclosed by the practice for the following purposes:

Administration purposes in the operation of our health service.
Billing purposes, including compliance with Medicare requirements
Follow-up reminder/recall notices for the treatment and preventative healthcare, frequency issues by SMS
Disclosure to others involved in your health care, including treating doctors and specialists outside this health service. This may occur through a referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals.
Accreditation and quality assurance activities to improve individual and community health care and practice management.
For legal related disclosure as required by a court of law.
Fur use when seeking treatment by other practitioners in this practice.

At all time we are required to ensure your details are treated with utmost confidentiality. Your records are very important and we take all steps necessary to ensure they remain confidential.

I have read the information above and understand why my information is being collected and the purpose for which my information is collected. I also give permission for my persona information to be used as described above, including via SMS to my mobile phone number.

I understand that payment of the account is due on the day of treatment.

Please note your appointment is reserved exclusively for you, Cancellation of less than 48 hours’ notice may incur a fee.

You will be contacted approximately 3 – 4 days prior to your appointment either by SMS or phone call to confirm. We kindly ask if you must change your appointment time that at least 48 hours’ notice is given. This allows us time to offer your appointment time to another patient.

Thanks again for choosing Burnside Dental Practice.

We look forward to meeting you.

Welcome to Burnside Dental Practice

Thank you for choosing Burnside Dental Practice and trusting our friendly team to look after you and your oral health care.

We have been providing quality dental care for many years. Our practice consists of four dentists and a great team of Oral Health Therapists and Hygienists.

Location: We are located at 537 Glynburn Road, Hazelwood Park.

Parking: Parking is available on Glynburn Road as well as our car park at the rear of the premises as well as a rear entrance into the practice. Disable parking is also located at the front of the practice on Glynburn Road.

Our Treatment Services

Our treatment services range from routine dental exam and hygiene visits, to restorations, crowns, extractions and implant treatment and dental emergencies. We also offer services to be completed under IV sedation.

If your booking has been made for a full examination including dental clean you will be booked in with one of our Oral Health Therapists or Hygienists for your dental clean and during this visit you will also be seen by one of our Dentists.

If your visiting Burnside Dental regarding a specific reason e.g broken tooth, dental pain, dental emergency than you will be seen by one of our dentists.

We offer online bookings for appointments. If you find a time online is not suitable then please contact us on 8364 2557 so we can arrange a booking for you.

Following your visit if further treatment is required, we will provide you with a quote and some health funds will allow us to find out regarding your dental benefits so you will be aware of any gap payments.

Please find attached our online new patient form. We can assure you that your details are kept confidential once this form is submitted.