Medical History Questionnaire Form - Dental Care Centre Page 2
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2PRIVACY STATEMENT
Pacific Smiles Group Limited (“PSG”) respects your right to privacy and considers all of the information you have
provided in this form to be personal information for the purposes of the Privacy Act 1988 (C’th) as amended
(“Privacy Act”).
Why PSG collects your personal information?
PSG collects your personal information primarily to enable it to provide health care services to you in the most
appropriate and efficient way. PSG, its related companies or agents (“Related Persons”) may also use this
information to promote health and related services to you or for other purposes permitted under the Privacy Act.
How PSG collects your personal information
Where possible we collect your personal information directly from you and where that is not reasonably
practicable we may collect your personal information from other sources.
PSG may collect personal information directly from you when:
•
you complete a medical history form such as this one;
•
you request information concerning PSG’s services in person, by phone or online.
In addition we may collect personal information from Related Persons or health service providers such as health
insurers, government agencies, hospitals, doctors and medical specialists.
We may provide information to Related Persons of PSG to assist them in developing and promoting health-
related products and services that may be of interest to you (unless you ask us not to).
How does PSG use your personal information?
PSG uses your personal information in accordance with National Privacy Principles. The personal information
is used to:
•
provide you with health and related services, including appointments and follow up services;
•
promote the health-related products and services of PSG and Related Persons.
Your agreement
By providing your personal information to us in this form or by other means you acknowledge and agree that
PSG may:
•
collect and use your personal information to provide health and related services to you;
•
collect and use your personal information to contact you for market research and to provide you with
information and offers about health-related products and services offered by PSG and Related Persons; and
•
disclose your personal information on a confidential basis to Related Persons who may contact you for
promotional and informational purposes in relation to health-related products and services.
Our staff may contact you on available telephone numbers and email addresses. When our staff contact you and
you are not available, they may leave messages which identify the caller or sender and the purpose for which
the communication is made.
Whenever you are provided with market research or marketing information by PSG or Related Persons you
will be offered the opportunity to inform us if you do not want your personal information to be used for those
purposes in the future.
Please refer to PSG’s Privacy Policy at for further details or contact the Privacy
Officer via email to .au or mail to The Privacy Officer, PO Box 2246, Greenhills,
NSW 2323, should you have any questions, comments or concerns regarding privacy matters or you do not want
your personal information used for marketing purposes.
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