Welcome to Dental Distinction
Message from Dr Golbarani Welcome to Dental Distinction
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Welcome Questionnaire
 

WE RESPECT YOUR PRIVACY

In order to provide you with the highest standard of dental care, this practice is required to collect personal information from
you. This information covers basic details such as your name, address and telephone number, but it is also necessary for us to obtain from you details regarding your general health and past medical or surgical treatments and procedures. Without this general health profile, the treating Dentist or Hygienist is unable to plan your care properly.

Naturally, some of this information is of a personal nature, some of it may be regarded as ‘sensitive’ and not the sort of
information you would wish to be unnecessarily disclosed to others. We value the need to safeguard this information and in
accordance with the principles laid down in privacy legislation and the guidelines issued by the Australian Dental Association, we would like to assure you that:

  • This information will only be used by the treating Dentist or Hygienist in order to deliver your care to the highest
    standards
  • It will not be disclosed to those not associated with your treatment without your expressed consent
  • You may seek access to the information held about you and we provide this access without undue delay. This access might be by inspection of your dental records at the time of your appointment or by special access or copying of information at other times
  • There will be no charge made for requesting this information but there may be fees levied just to cover the costs associated with the processing of this request or the copying of information.
  • We will take reasonable steps to ensure at all times that the details we keep about you are accurate, complete and up-todate
  • We will take all reasonable steps to protect this information from misuse or loss and from unauthorised access, modification or disclosure.
  • Our staff are trained to respect these principles at all times
If you have any questions regarding the information we collect from you and hold in your dental records, please do not
hesitate to ask us. We are acting in your interests at all times.
Prof
 

Full Name

Address

Home phone

Work phone
Mobile phone
Email
Date of birth
Occupation
Employer
Health insurance
Contact person in case of emergency
Who referred you to our office?
Person responsible for dental investment
When was your last dental visit?
Why did you leave your last dentist?
What has been your concern with previous dental visits?
What is your main dental concern today?
   
 
Cosmetic Smile MakeoverOrthodontic SolutionsAmalgam Removal
 
 
Shop 14 Samford Central,
Mt. Glorious Road
Samford QLD 4520