Fill Appointment

We Provide Reasons To Smile

Bondi Junction • Gosford • Hornsby • East Maitland

May we assure you that we shall endeavour to make our association mutually enjoyable. There will be an estimate for the treatment prior to commencement, payments must be made for treatment completed at each appointment.

Our front staff will help you with most suitable appointment times.

Please answer these questions as completely as possible, it will assist us greatly to provide you with the best treatment. Thank You

MEDICAL HISTORY ( Please tick)

Heart Attack Artificial Valves Rheumatic Fever   Nervous Disorders  
High Blood Pressure Abnormal bleeding   Asthma Thyroid Disorders 
Heart Murmer  Epilepsy   Ulcer/ Hiatus hernia  HIV/ AIDS 
Cardiac surgery  Diabetes  Anaemia  Anaesthetic Problems  
Pacemaker  Hepatitis A, B, C or D  Arthritis   Cancer 


Consent for Treatment

I hereby authorize the dentist or designated staff to take x-rays, study models, photographs and other diagnostic aids deemed appropriate to make a thorough diagnosis.

Upon such diagnosis, I authorize the dentist or designated staff to perform all recommended treatment mutually agreed upon by me and employ such assistance is required to provide proper care.

I agree to the use of anaesthetics, sedatives and other medications as necessary. I fully understand that using anaesthetic agents embodies certain risks. I can ask for complete recital of any possible complications.

I give consent to share my medical records when it has been deemed necessary to seek an external professional advice, opinion or for referral purposes.

I am the responsible person 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 acknowledge that a 24 hours notice is required to cancel or reschedule my dental booking. A short notice or absence without notice will arise a cancellation fee as per current tariff.