New Patient Registration - Southern Oral & Maxillofacial Surgeons

Title*

Given Name*

Surname*

Preferred Name

Gender*

Residential Address**

Suburb**

Postcode*

Postal Address

Date of Birth*

Age*

Contact Phone Number**

Occupation*

Email Correspondence

Yes, I would like to receive emails regarding my treatment – eg: medical certificates

Name of Person Responsible for fees:*

Self

Other

Contact Name*

Medicare Number*

Ref Number*

Medicare Expiry Date*

Vet Affairs Gold No

If child is 14 or under please confirm:

Yes, I am a minor

Parents Name

Parents DOB

Medicare ref. No.

Do you have Private Health Insurance?*

Yes

Fund Name*

Membership No*

Ref Number*

Do you have Hospital Cover?*

Yes

Do you have Dental Cover?*

Yes

Cardiologist

Dentist

Doctor

Practice

Do you have any of the following*

Anxiety

Asthma

Diabetes

Emphysema

Epilepsy

Excess bleeding

Heart condition

Hepatitis

HIV / AIDS

Osteoporosis

Pacemaker

Stroke

N/A

Wheelchair bound

Blood Pressure*

High

Low

N/A

Are you pregnant?*

Yes

Do you smoke?*

Yes

Do you vape?*

Yes

Are you on Prolia?*

Yes

Any allergies?*

Yes

Date Last Given Prolia*

Please list allergies**

Are you on blood thinners eg: Warfarin/Aspirin*

Yes

Have you had any major operations / serious illnesses?*

Yes

List any major operations / serious illnesses or N/A if not applicable*

Are you on any current medications?*

Yes

List your current medications here... "We require the complete list of medications prior to the day of your appointment" **

Do you have any problems with general anaesthetic?*

Yes

List any problems with general anaesthetic or N/A if not applicable*

Aboriginal/Torres Strait Islander origin

Yes

Special Needs

Yes

Special Needs Details

Emergency Contact

Relationship

Phone No.

Please take care to fill out this form completely. We rely on all your information to be able to provide you with appropriate medical services.

Privacy Policy – We value the need to safeguard this information and, in accordance with the principles laid down in privacy legislation we would like to assure you that this information is only used by the treating doctor in order to deliver your care to the highest standards. I also give consent for medical information to be used by these rooms for the benefit of my treatment. Our complete privacy Policy is available at reception.

Consent*

I understand that payment of accounts is my responsibility and that my Health Fund may not fully cover these fees. In the event where my overdue account is referred to a collection agency and/or law firm, I understand that I will be liable for all costs incurred.*

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