Innisfail Dentists
The First Fully Accredited Dental Practice in Innisfail

Patients Form

To ensure we are looking after your needs, please complete the following questionnaire. If you would like to know more about why we collect this information and what we do with it, you can read our privacy policy.

Mr Mrs Miss Ms Dr
Male Female

Have you had any of the following?

Yes No
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Yes No

Dental Concerns

Yes No
Yes No

Referral

Consent for Treatment

1. I hereby authorise the dentist or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.

2. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3. I agree to the use of anaesthetics, sedatives and other medication as necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand I can ask for a complete recital of any possible complications.

4. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made.

WE EXPECT AND APPRECIATE PAYMENT AT TIME OF SERVICE WE ACCEPT VISA, MASTERCARD, PERSONAL/BANK CHEQUE, EFTPOS AND CASH

Dr A. Jay Lo
29 Owen Street P.O.Box 1057 INNISFAIL Q 4860
(07) 4061 1134

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