Patient Registration Form

PATIENT DETAILS

First and Middle Name(s) *

Last Name *

Preferred Name

Date of Birth *

Gender *

MaleFemaleOther

Country of Birth

ATSI

AboriginalTorres Strait IslanderNone of the Above

Occupation

PATIENT CONTACT DETAILS

Home Phone

Mobile Phone *

Work Phone

Email

Address *

City / Suburb *

State *

Postcode *

Postal Address (if different)

City / Suburb

State

Postcode

Guardian (if applicable)

Guardian - Relationship

FatherMother RelativeOther

EMERGENCY CONTACT DETAILS

Name *

Address

City / Suburb

State

Postcode

Home Phone

Mobile Phone *

Work Phone

Email

REFERRER AND HEALTH PRACTITIONER DETAILS

Referring Practitioner’s Name

Clinic Name

Address

Phone

Family Doctor/ General Practitioner Name

Clinic Name

Address

Phone

General Dentist (if different to referring practitioner)

Clinic Name

Address

Phone

MEDICARE

Medicare First Name

Medicare Surname

Medicare Card No.

Ref No. (digit before your name)

Expiry

PRIVATE HEALTH INSURANCE

Do you have Private Health Insurance?

YesNo

Do you have Hospital Cover?

YesNo

Fund Name

Membership No.

Ref No. (digit before your name)

Expiry

Do you have Dental Extras Cover?

YesNo

Extras Fund Name (if different to above)

Membership No.

Ref No. (digit before your name)

Expiry

DVA / CTP / RETURN TO WORK SA

DVA No.

Expiry

CTP/ Return to Work SA Insurer

Claim No.

Claims Contact

Date of Injury / Accident

PERSON RESPONSIBLE FOR ACCOUNT/ CLAIMANT

Who is responsible for this account?

Self Other

If person responsible for the account is Self, please move on to the next Section (MEDICAL SUMMARY).

Name (Claimant)

Date of Birth (Claimant) *

Mobile Phone (Claimant)

Email (Claimant)

For the person responsible for the account, in particular if the patient is a minor, please supply your Medicare and Private Fund details as applicable, so that we can submit a claim for you for the consultation.

Medicare First Name (Claimant)

Medicare Last Name (Claimant)

Medicare Card Number (Claimant)

Ref No. (Claimant)

Expiry

MEDICAL SUMMARY

Rheumatic Fever

Yes No

Diabetes

Type IType II No

Heart Problems

YesNo

Kidney Disease

Yes No

Heart Murmur

Yes No

Lung Conditions eg asthma

YesNo

High Blood Pressure

Yes No

Mental Conditions eg Depression

Yes No

Osteoporosis

YesNo

Stomach Reflux / Ulcer

Yes No

Epilepsy

YesNo

Excessive Bleeding or Blood Thinners

Yes No

Cancer

YesNo

Radiation History

YesNo

Blood Borne Infectious Diseases Eg HIV/ Hepatitis

YesNoUnknown

Have you EVER taken any medications or had regular injections for Osteoporosis or Bone Conditions/lesions (Eg Denosumab, Prolia, Fosamax, Actonel, Pamisol, Didronel or Aredia)

Yes No

If you have responded "yes" to any of the above questions, please provide further details about your condition(s) as relevant. Please list any other Medical Conditions not included above.

Are there any other risk factors you would like to discuss during your consultation?

YesNo

Have you smoked cigarettes/cigars/vape within the last 4 weeks?

Yes No

If yes, how many per day?

Please list all previous operations and when this occurred.

ALLERGIES

Penicillin

Yes No

Latex

Yes No

Aspirin

Yes No

Elastoplast or Tapes

Yes No

Please list any other allergies you may have. (Medication / Food / Contact)

CURRENT MEDICATIONS

Please List all Medications you are currently taking (including vitamin supplements and inhalers). Please provide frequency and dosages.

FEMALES ONLY

Are you pregnant?

Yes No

ANAESTHETIC HISTORY

Have you ever had problems with general/local anaesthesia?

Yes No

If "yes", please provide details.

Privacy Statement: Our practice respects your right to privacy and complies with the legislation (APP) relating to the collection, storage, use and disclosure of health information. For more information, please ask us for a copy of our Privacy Policy.

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

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Today's Date

(Must be signed by Patient or Parent/Guardian of patient under 18 years)

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