New patient form

To ensure we have all the information we need for your first visit, please fill out the appropriate health history in advance of your Initial Appointment.

Fields marked * are required.

Patient Information

If under 18 years, please enter details of the person financially responsible for this patient

Treatment preference

Accepted file types: jpg, gif, png, pdf (up to 5 files only; max file size 100MB)

Payment preference options


In accordance with the Privacy Act 1988 and the Health Records and Information Privacy Act 2002

Dan Smethurst Orthodontics respects your right to privacy. We realise that it is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our practice and to whom this information might be disclosed.

The policy of our practice is to follow these procedures:

  • The information collected on this form will be used for the purpose of providing treatment to you. Personal information such as your name, address and health insurance details will be used for the purpose of addressing accounts to you, as well as processing payments and writing to you about any issues affecting your treatment.
  • We may disclose your health information to other health care professionals, or require it from them if in our judgement, that is necessary in the context of your treatment. In that event, disclosure of your personal details will be minimised wherever possible.
  • We may also use parts of your health information for research purposes, in study groups or at seminars as this may provide benefit to other patients. Should that happen, your personal identity will not be disclosed without your consent to do so.
  • Your patient history, treatment records, x-rays and any other material relevant to your treatment will be kept here. You may inspect or request copies of your treatment records at any time, or seek an explanation from the dentist. If you want copies, a fee may apply. If you require an explanation of your records or a written summary, a consultation fee or other charge may apply.
  • If any of the information we have about you is inaccurate, you may ask us to alter our records accordingly.
  • Dan Smethurst Orthodontics may request to take images for social media; this might be verbal or written consent from the patient or parent/guardian.
  • Contact information will be used to follow up and inform as necessary; before, during and after treatment.

You can otherwise rest assured that your health information will be treated with the utmost confidentiality. Disclosure will not be made to any person not involved in either your treatment or the administration of this practice, without your prior written consent unless we are required to do so by law. If you have any queries or concerns about our handling of your health information, please do not hesitate to raise these concerns with our practice.

I acknowledge that I have read and understood the Privacy Policy and consent to the use of my/the patient’s health information.