New Patient Form

To provide you with the highest standard of orthodontic care, it is important that we are informed of the patient’s medical history, as certain conditions may
affect the success of treatment. It is your responsibility to inform Dr Chisholm or our staff of any changes to medical and/or dental health throughout the
course of treatment. All information you provide is strictly confidential and will be handled in accordance with our privacy policy.

We Respect Your Privacy

To provide you with the best possible orthodontic care, we need to collect some personal information. This includes your name,
address, phone number, and details about your general health and any past medical or surgical history. We need this information
to safely and properly plan your treatment.

We understand that some of this information is private and sensitive. Please be assured:

• Your information is only used to provide you with the highest standard of orthodontic care.
• We will not share your information with anyone not involved in your treatment without your permission.
• We may share relevant information with other healthcare providers involved in your care (such as specialists you are
  referred to) if it is necessary for your treatment. We will only share what is needed.
• You have the right to access the information we hold about you. This may include viewing or requesting copies of your
  records.
• We take reasonable steps to keep your information accurate, up to date, secure, and protected from misuse or unauthorised access.

If you have any questions about how we collect or use your information, please speak with our team. We are always acting in
your best interests.

CONSENT FOR TREATMENT

• I confirm that the information I have provided is true and correct to the best of my knowledge. If further details are needed, I give permission for Dr Neena Chisholm and/or team to contact my medical practitioner, who may share relevant information to assist with my care.
• I give consent for Dr Neena Chisholm and/or team to perform any examinations, records, and procedures necessary to properly assess and diagnose the patient’s dental and orthodontic needs.
• I understand that I am responsible for the payment of all services provided. Payment is due at the time of each appointment unless other arrangements have been made in advance. If any outstanding amounts require follow-up for payment, any associated costs may be my responsibility.
• As appointments are reserved especially for each patient, we kindly ask for at least 48 hours’ notice if an appointment needs to be changed. A cancellation fee may apply for late changes or missed appointments.

By signing below, you acknowledge that you have read and understood our Privacy Policy. You hereby consent to treatment and authorise the use of your health information in accordance with the terms outlined above.