Patient Registration & Privacy Form

Patient Registration & Privacy Form

Personal Information:

* indicates required field


Medical Information:


























Dental Information:






















Privacy Agreement & Patient Consent:
I understand the shine dental group and associated Medical & Dental clinics comply with the privacy act (1988) and as part of their privacy are committed to protecting the privacy of individuals and their personal information. by ticking and submitting below indicates that i have read the above and consent to Shine Dental Group collecting, using, storing and disposing of my personal information; the release of relevant personal information to other health professionals to allow quality dental care; inclusion in a recall register to be advices of the following up visits. I understand I may withdraw my consent for Shine Dental group to us and disclose my personal information (except when legal obligations must be met).