Medical History Form

Patient Medical History Form

Patient Medical History Form

If you are a new patient or an existing patient wanting to update your details please feel free to download the Kitchener Street Dental Medical History Form and bring to your next appointment.

It is important to know details about your medical history, as these could affect the success of your dental treatment. The information you provide is confidential and will be handled in accordance with our privacy policy.

You can download a copy of our medical history form from the following link:

Patient Medical History Form

This practice collects all of your Personal Health Information as a part of your medical record.

This information is collected so your Doctor has all of your relevant information necessary to provide you with the medical treatment that you require. This practice is managed under strict guidelines governed by the Private Sector Privacy Amendment Act, enacted on the 12th of March 2014.

This information may be collected, used and disclosed for the following reasons:

• For the communication of relevant information with other treating doctors, specialists, allied health professionals, and other health care professionals
• For follow up reminder and recall notices
• Administratively- Accounting purposes / Medicare / Health Insurance
• Quality assurance activities such as accreditation
• Organisations authorised by Law to request information from the practice
• For disease notification as required by law (eg: infectious diseases)

Your personal information is stored on our computer system . This information may only be accessed by authorised persons. Unless you specifically instruct the Doctor, it will be assumed that you have given this practice permission to disclose the information it regards as necessary, to any relevant organisations for the purpose of providing you with the requested medical treatment.

It is important you keep the practice updated of any changes in your personal details such as addresses, and medical details (such as medications prescribed by other practitioners), so our information we keep on yourself is accurate.

Any information that is disposed of by this practice is done so in a secure manner. We are obliged by Law to keep all our records for a period of seven years. Unless otherwise requested by you, the practice will keep such information until the practice believes it is no longer relevant to do so.