Patient Medical History Form

Dental Patient History Form

Here at Beenleigh Marketplace Dental, it’s imperative we know your whole medical history.

It is important to know details about your medical history as these could affect the success of oral health care (dental treatment).

The information you provide is confidential and will be handled in accordance with our privacy policy which is shown on the second page of this form.

Please fill out the form below or click here to download and print it.

If you have any questions about the form or want to learn more, please don’t hesitate to call us and speak to our friendly staff.

PRIVACY POLICY

This privacy policy outlines how we collect and use your personal information, including health data, and when we may share it with third parties.

Why and when your consent is necessary?
When registering as a patient at our practice, you authorise our dental practitioners and staff to utilize your personal information to deliver optimal dental care. Access to your data will be restricted to relevant personnel only. Should there be any alternative use of your information, we will typically seek your further consent, unless obtaining such consent is impractical or unreasonable, and an exception under the Privacy Act 1988 (Cth) is applicable.

Why do we collect, use, hold and share your personal information?
Our practice requires the collection of your personal information to deliver dental services effectively. Primarily, we gather, utilize, store, and share this data to oversee your dental well-being. Additionally, we employ it for ancillary business functions like financial transactions, practice evaluations, and operational procedures such as staff training.

Your information might be utilized to furnish details about our treatments. Should you prefer not to receive marketing materials directly, please notify our reception. In terms of our website, we may employ cookies or similar tracking technology to compile aggregated, non-personally identifiable data. This information aids us in enhancing the content across our digital platforms. You have the option to disable cookies in your web browser if preferred.

What personal information do we collect?

In order to provide you with the best possible care, we’ll collect various pieces of information from you. This may include your basic identity details such as your name, address, date of birth, gender, occupation, email address, telephone number, and information about your next of kin. Additionally, we’ll need to gather certain administrative and billing information, like your Medicare number, DVA number, health insurance details, and bank account information. From a medical perspective, we’ll also need to gather your medical history, clinical notes, test results, treatment plans, prescribed medications, referral details, and any relevant clinical digital images. Rest assured, all of this information is handled securely and with utmost confidentiality to ensure your privacy and well-being.

When you use our website, we may collect personal information, including online inquiries, device details, IP addresses, visited pages, and location data. Not providing all requested information may affect our ability to provide dental services.

How do we collect and hold personal information?

We collect personal information about you in several ways, including from:

• you directly (including through our websites and social media pages, when you complete an entry form for any competition and/or trade promotion
  when you complete a new patient form, when you interact with a member of our team, e.g. a receptionist or when you receive dental services from
  one of the dental practitioners operating from our Centres);
• someone with responsibility for you (such as your parent, carer or guardian);
• independent dental practitioners operating from our Centres, including as recorded in your patient records;
• external providers (such as your insurance or a referring dentist) which is provided to a Centre and included in your patient record;
• government agencies such as the Department of Veterans Affairs or Medicare, that you may use for assistance to access the dental services at our
  Centres; and
• contractors or service providers engaged to carry out functions on our, or our dental practitioners’, behalf (such as call centres and other providers
  of recall, marketing campaigns and other communication services).

How do we store and protect your personal information?

We securely store your personal information in multiple formats at our practice, including paper, electronic, and digital visual records like X-rays and photos. Electronic records are kept in a protected network environment, accessible only through password-protected systems. Our staff and contractors are bound by confidentiality agreements, and we have robust security breach policies in place to prevent and manage any loss of confidential data.

How can you access and correct your personal information at our practice?

You have the right to request access to, and correction of, your personal information. Our practice acknowledges patients may request access to their dental records. We ask that you put this request in writing to our reception to info@bmpdental.com.au. Our practice will take reasonable steps to correct your personal information where the information is not accurate or up to date. From time to time, we will ask you to verify that your personal information held by our practice is correct and current.

How can you lodge a privacy-related complaint, and how will the complaint be handled at our practice?

If you have any concerns or wish to file a complaint regarding the handling of your personal information, please reach out to the Privacy Officer by sending an email to info@bmpdental.com. Kindly include your name, email address, and/or telephone number, along with a clear description of your concerns or complaint. We strive to address your complaint promptly upon receipt. Should you remain dissatisfied with our response, we will guide you through additional steps you can take to address the matter further.