Dental Corporation Pty Ltd (ABN 92 124 730 874) t/as Mint*d Smile (Dental Corporation) collects personal information that is necessary for providing its services to you and to perform its business functions and activities. Dental Corporation may not be able to provide you with its products and services if you do not supply this information.
Dental Corporation may disclose your personal information to members of the Bupa Group, or to the third parties engaged by us or acting on our behalf. We may also provide details to your health insurer if you choose to make a health insurance claim for your treatment. If you provide Dental Corporation with personal information about another person, it is your responsibility to inform them that you have done so and that they have a right to access their information.
All personal information collected by Dental Corporation is handled in accordance with our privacy policy, which can be viewed at
https://www.mintdsmile.com.au/privacy-policy. This policy also contains information about accessing your information, requesting corrections to your information and how to make a complaint about the handling of your information.
By signing this form you hereby agree and acknowledge that: (i) you have accurately completed this form to the best of your knowledge; (ii) you consent to any treatment agreed upon to be carried out by the dentists and their staff; (iii) you are responsible for payment of all services rendered on your behalf and on behalf of your dependants; (iv) payment is due at the time of service unless other arrangements have been made; and (v) your dentist may take images of your teeth both before and after your treatment. These images may be used in a practice portfolio to showcase examples of dental work to other patients (your identity will remain anonymous). This personal information will be handled in accordance with Dental Corporation's privacy policy.
If you have any questions or concerns about how your personal information has been handled, please direct your correspondence to: The Privacy Officer, Dental Corporation, Level 15, 33 Exhibition Street, Melbourne, VIC, 3000 or email
BD.PracticeStandards@bupa.com.au