New patient form

To help us get to know you and prepare for your first appointment, please complete our new patient form before your visit. This form lets you share important details about your dental history, medical background, and smile goals so our specialist team can personalise your treatment from the start.

New patient form

Patient Details

Title *
Gender *

Medical History

Have you ever had any of the following conditions?*
Are you taking any medications at present?*
Do you have any allergies we need to be aware of?*
Have you had a serious illness, operation or been hospitalized within the last 5 years?*
Have you ever suffered from problems with your jaw (TMJ) joints? Including clicking, soreness or limitation of movement?*
Do you have any other illnesses or medical conditions you would like to draw our attention to?*

Account Information (Parent/Guardian)

Is the patient responsible for the account?*

If NO, please continue with this section:

Title *

PRIVACY NOTICE – ORTHODONTIC PATIENTS

Smile Partners (NT) Pty Ltd (Darwin Orthodontics) collects personal and health information about you, from you directly and from other sources such as other health practitioners involved in your relevant care and treatment, to provide you with orthodontic services and treatment. If you do not provide or Darwin Orthodontics cannot otherwise collect all the information we request or need, Darwin Orthodontics may not be able to provide you with the requested services and/or treatments. We may also use your information to manage and operate our practice, including to improve our services and treatment.

Sharing your personal information

Darwin Orthodontics may share your personal information with third parties as reasonably necessary to provide you with orthodontic services or treatment, including other health practitioners involved in your care, Medicare and your health fund, or where we engage third party service providers in relation to the management or operation of our practice. Some of these organisations may store data on international servers.

From time to time, we may also seek to use and share your information and images for research and education purposes. Unless you provide your consent below, we will not use or share identified information or images for this purpose. We will always ensure that confidentiality is maintained over any of your information that we do share with other entities.

Direct marketing

With your consent, we may use your contact details to send you (by telephone, post, email or SMS) marketing communications to let you know about products, services, offers and events. You can opt out of marketing communications at any time, by following the unsubscribe function in the message we send or emailing us at practicemanager@darwinortho.com.au. From time to time, Darwin Orthodontics uses patient images to promote its services and treatment, including through social media (eg Facebook, Instagram). Unless you consent to such use below, we will not use images of you for marketing or promotional purposes.

Further information

Our privacy policy, which is available at https://www.darwinortho.com.au/privacy-policy/ includes our contact details, explains more about the types of personal information we usually collect and how we handle your personal information, how you can seek access to and correction of your personal information, how to make a privacy complaint and how we deal with complaints.

PRIVACY CONSENT

I consent to Darwin Orthodontics collecting my/my child's personal and health information as described above
Using my information and images for research and educational purposes
Using my personal information and certain images for marketing and promotional purposes (if I consent to this, my image and/or name would be publicly available):

For further information about how we use your data, please see our privacy policy.