New Patient Registration Form

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    Title:

    Surname (required):

    First & Middle Name(s) (required):

    Preferred Name:

    Country of Birth:

    Date of Birth:

    Age:

    Sex:
    Marital Status:

    Occupation:

    Street Address:

    Postal Address (if different):

    Suburb:

    State:

    Postcode:

    Email:

    Person responsible for account:


    Person responsible for Account:

    Person responsible contact details
    Address:

    Phone:

    Email:

    Guardian/ Next of kin (if applicable):

    Guardian Phone:

    REFERRAL AND PRACTITIONER DETAILS:


    Referring Practitioner:

    Address:

    Phone:

    General Medical Practitioner (GP):

    Address:

    Phone:

    General Dentist:

    Address:

    Phone:

    MEDICARE & HEALTH INSURANCE DETAILS:

    Medicare Details:


    Medicare Card (Card No 10 Digits on card):

    Expiry Date MM/YY:

    Ref No. (digit next to your name):

    Private Health Insurance:


    Fund Name:

    Member No:

    Dental Extras Fund:
    NoYes
    Hospital Cover:
    NoYes

    Veteran Affairs:


    Card No:

    Expiry Date:

    TAC/Workcover


    Insurer:

    Claim No:

    Claims Contact:

    MEDICAL SUMMARY

    HAVE YOU HAD OR CURRENTLY HAVE:
    Rheumatic feverNoYes
    DiabetesNoYes
    Heart problemsNoYes
    Heart murmurNoYes
    EpilepsyNoYes
    Kidney diseaseNoYes
    HepatitisNoYes
    AsthmaNoYes
    High blood pressureNoYes
    OsteoporosisNoYes
    Stomach reflux/ulcerNoYes
    Excessive bleedingNoYes

     

    DO YOU HAVE ANY ALLERGIES TO:
    PenicillinNoYes
    AspirinNoYes
    LatexNoYes
    Elastoplast or tapesNoYes

     


    Any other medication allergies?: NoYes If yes, please provide details in box below (180 or less characters):

    Any food allergies?: NoYes

    Any other allergies?: NoYes If yes, please provide details in box below (180 or less characters):

    Have you smoked cigarettes/cigars within the last 4 weeks?: NoYes
    Are there any other "risk factors" you need to discuss in your consultation? (180 or less characters):

    Have you EVER taken any medications for osteoporosis or bone conditions/lesions? (eg. Fosamax, Actonel, Zometa, Pamisol, Didronel, Didrocal, or Aredia): NoYes
    Please list ALL medications you are currently taking (including vitamin supplements and inhalers) (180 or less characters):

    Please list ALL previous operations (180 or less characters):

    Describe any serious illness you have previously suffered (180 or less characters):

    General Anaesthetics


    Have you had problems with general anaesthetics or a family history of malignant hyperthermia? (180 or less characters):

    Females


    Are you pregnant?: NoYes
    Are you taking the oral contraceptive pill?: NoYes

    PRIVACY STATEMENT


    Our practice respects your right to privacy and complies with the legislation relating to the collection, storage, use and disclosure of health information. For more information please ask for the Privacy Statement handout.

    Please check the box below to prove you are a human, then click the 'Send' button All Emails are encrypted and sent securely.