Patient Registration

Patient Information

  • PATIENT INFORMATION: Please print in block letters
  • REFERRAL AND PRACTITIONER DETAILS
  • MEDICARE & HEALTH INSURANCE DETAILS
  • MEDICAL SUMMARY

GENERAL

Surname

Middle Name

First Name

Preferred name

Gender

Date of Birth

Age

Country of Birth

Occupation

Street Address

Address

Suburb

State

Postcode

Postal Address (If different)

Address

Suburb

State

Postcode

Person responsible for account

Name

Address

Phone

CONTACT DETAILS

Home

Mobile

Work

Email

Preferred Form of Contact

Guardian/ Next of kin (If applicable)

Phone

Post surgical contact name

Post surgical contact phone

Referring practitioner

Name

Address

Phone

General Medical Practitioner (GP)

Name

Address

Phone

General Dentist

Name

Address

Phone

Medicare Details

Card No.

Ref No (digit next to your name)

Expiry Date

Private Health Insurance

Fund Name

Member No.

Dental Extras Fund

Hospital Cover

Veteran Affairs

Card No.

Expiry Date

TAC/Workcover

Insurer

Claim No.

Claims Contact

Have you had or currently have...

Rheumatic fever

ARE YOU A DIABETIC ?

DIABETES

Heart problems

Heart murmur

Epilepsy

Kidney disease

Hepatitis

Asthma

High blood pressure

Osteoporosis

Stomach reflux/ulcer

Excessive bleeding

Do you have Allergies to...

Penicillin

Aspirin

Any other medication?

Any foods?

List

Latex

Elastoplast or tapes

Any other allergies?

List

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

Have you EVER taken any medications or had regular injections for osteoporosis or bone conditions/lesions? (eg. Denosumab, Prolia, Fosamax, Actonel, Zometa, Pamisol, Didronel, Didrocal, or Aredia)

Please list ALL medications you are currently taking (including vitamin supplements and inhalers)

Please list ALL medications you are currently taking (including vitamin supplements and inhalers)

Please list ALL previous operations

Please list ALL previous operations

Describe any serious illness you have previously suffered

Describe any serious illness you have previously suffered

Females

Are you pregnant?

Are you taking the oral contraceptive pill?

Have you had problems with general anaesthetics or a family history of malignant hyperthermia?

Have you had problems with general anaesthetics or a family history of malignant hyperthermia?

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