4722 6299 | 4722 6966
110 Lethbridge St, Penrith
In order to render dental treatment of a high standard, it is necessary to have the following information. Please fill in this form completely. The information you provide to us on this form is strictly confidential. Your information will not be released to any third parties without your prior written consent.
I agree that the above is a true and accurate record. I understand that Lethbridge Dental Clinic requires payment on the day of treatment. Any expenses, cost or disbursements incurred by Lethbridge Dental Clinic in recovering any outstanding monies including debt collection fees and solicitor costs shall be paid by the responsible party above. I further acknowledge that failure to attend any appointment without 24 hour’s notice will result in a NON-REFUNDABLE $30 CANCELLATION FEE, and I will need to deposit up to $100 prior to future appointments being scheduled. I have read and agree with the privacy statement provided to me.
PLEASE NOTE: This form will be electronically copied to your clinical record file and the original will be subsequently destroyed. By signing this document, you agree to this process. This form is a guide only and you should discuss any relevant matters with your dentist prior to the commencement of any dental treatment.
I also authorise the dentist and support staff to take photographs, and/or videos of my/my dependant’s face, jaws and teeth, before, during and after treatment.
I consent to allow the photographs/videos to be used for the following: