Patient Registration and Medical History Form

Any questions please call reception on (03) 9509 5111 or email reception@oralsurgeryclinics.com.au. 

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• Required Fields

PERSONAL DETAILS

Please enter details as per Medicare

Patient Title •

First Name •

Surname •

Date of Birth •

Address •

Suburb •

Post Code •

State •

Occupation •

Mobile Phone •

Email • (If patient is under 18 please provide guardians email)

To improve efficiency we send correspondence via email
Please tick if you DON’T have access to email   

You will only be sent information regarding your treatment.

MEDICAL HISTORY

This information is confidential

Emergency contact name •

Contact number •

Relationship to patient •

Have you ever suffered from the following?

   Angina
   Arthritis
   Asthma
   Bleeding problems
   Complications with anesthetics
   Diabetes
   Epilepsy/fits
   Heart Problems
   Hepatitis A
   High Blood Pressure
   Liver problems
   Lung problems
   Osteoporosis
   Rheumatic fever
   Stroke
   Thrombosis

Do you have any Allergies? •

Do you take any antiresorptive medications? (eg Prolia, Bisphosphonates)

Do you have an artificial heart valve or joint replacement?

Details

Any other illnesses?

Details

Please list any medication you are taking (Including Ventolin puffers and contraceptive pill)

Do you smoke?

How many cigarettes per day?

Do you use recreational drugs?

Details

Ladies are you pregnant?

ACCOUNT DETAILS

Medicare Number

Reference Number (Number next to your name)

Private Health Insurance

Membership number

   Hospital Cover
   Dental Extras Cover


Person responsible for fees.

Name

Address

Relationship to Patient

Medicare Number

Reference Number (Number next to your name)

Date of Birth

Email (If different to patient)

Phone Number

CORONAVIRUS

Screening questions for Novel Coronavirus 2019 (COVID-19)

If you have cold and flu symptoms and have recently travelled overseas, or believe you may be at risk of coronavirus (COVID19), please advise us IMMEDIATELY before filling out this form.

Have you travelled overseas (any destination) within the last 14 days? •

If yes, please specify location

Dates of travel

Have you been in contact with a confirmed case of Novel Coronavirus 2019 •

If yes, provide details

Are you experiencing any cold or flu like symptoms? •

If yes, please specify symptoms

Additional Notes

I have read and accept the Privacy Policy below. •

PRIVACY POLICY

Our practice respects your right to privacy. We realise that it is important that you understand the purpose for which your personal and health information is collected, as well as how this information is used and to whom this information might be disclosed.

The policy of our practice is to follow these procedures:

  1. The information collected will be used for the purpose of providing treatment to you. Personal information such as your name, address and health insurance details will be used for the purpose of addressing account to you, as well as processing payments and writing to you about issues affecting you treatment.
  2. We may disclose your health information to other healthcare professionals and hospitals, or request it from them if it is necessary in the context of your treatment. Disclosure of your personal details will be minimized to relevant information.
  3. Information may be disclosed to and requested from other people or organizations in order to finalise accounts in a timely manner.
  4. Your assistance is requested by providing updated personal and health information at subsequent visits, particularly regarding changes to your health and medications. When additional information is provided we will keep your records up-todate, accurate and complete.
  5. Anonymous details of your health information and treatment may be used for research, study or educational purposes. Your personal identity would not be disclosed without your consent.
  6. Your medical history, treatment records, radiographs and any other material relevant to your treatment will be retained in a secure manner. When no longer required, information may be destroyed in accordance with government regulations.
  7. We will maintain and abide by a Practice Privacy Policy that conforms to Government regulations. You may request a copy of the current Practice Privacy Policy at any time.
  8. You may inspect or request copies of your records at any time or seek an explanation. Statutory fees will apply in relation to the type of access you seek.
  9. If any of the information we have about you is inaccurate, you may ask us to alter our records accordingly

You can otherwise rest assured that your personal and health information will be treated with the utmost confidentiality. Disclosure will not be made to any person not involved in either your treatment or the administration of this practice without your prior written consent. If you have any questions or concerns about our handling of your health information, please do not hesitate to discuss these issues with our practice staff.

Please be aware that if you have an appointment booked with us and you do not arrive or if you cancel with less that 24 hour notice a no show/cancelation fee may apply.

If the patient is under 18 years of age, a parent or guardian must sign and provide a daytime contact number.