Thank you for choosing Matamata Dental Centre for your dental needs. This form is an
important source of information for us. Please take time to complete it accurately.
Indicate your acceptance of check boxes by clicking within them.
Preferred title :
When did You last see a dentist?
What was the name of your last dentist?
How did you hear of Matamata Dental Centre ?
If you are under 16, please advise us of your parent/guardian's name
Please give us your parent/guardian's address, if applicable
Do you have dental insurance ?
Do you smoke ?
Matamata Dental Centre does not provide amalgam (silver) fillings. Are you happy to
If you have indicated 'No' to the above question, please contact reception for
referral to other dentists who use amalgam.
Although rare, accidental injury to staff can occur during handling of used
instruments. If this happens during the course of your treatment, Matamata Dental Centre
requires patient and staff member to undertake a bloodtest.
Do you agree to a confidential blood test ?
If you have indicated 'No' to the above question, please advise Reception staff
immediately to clarify this.
Matamata Dental Centre's financial policy is to request payment for all treatment on the day
of treatment. Credit arrangements, if any or
arrangements for receiving accounts, must be made in advance. We do offer payment
plans through Q card but reserve the
right to provide these at our discretion. Overdue accounts will reluctantly be
transferred to a debt collection agency
and will incur interest at 10% per annum. The cost of debt, interest and recovery
will be passed on to the account holder.
Matamata Dental Centre reserves the right to charge a cancellation fee for appointments
cancelled at less than 12 hours notice.
I confirm that the information provided above is true and correct. I provide general
consent for my treatment by the dentists at Matamata Dental Centre. I
also consent to the use of my records for communication. I further consent to use of
my records, xrays and photographs for scientific presentation in
conferences/print/web publications without compromise of my identitity. I also
further consent to Matamata Dental Centre's financial and cancellation policies as well.