Home
About
- About Nick Rutherford
- Appointment Policy
Post Operative Instructions
Hospital Admissions
Fee Structure
Hours
Contact

Home
About
- About Nick Rutherford
- Appointment Policy
Post Operative Instructions
Hospital Admissions
Fee Structure
Hours
Contact

Patient Registration

Patient Registration Form

Step 1 of 6

16%

Are you registering for a consultation with Dr Nick Rutherford, or are you registering for a hospital admission?*
- Registering for a consultation with Dr Nick Rutherford
- Registering for a Hospital Admission
Click here for Hospital Admission instructions for Epworth Freemasons

Click here for Hospital Admission instructions for NorthPark Private Hospital

Click here for Hospital Admission instructions for Warringal Private Hospital

Save and Continue Later

General
NAME*
First Middle Last
GENDER*
- Male
- Female
DATE OF BIRTH*
DD slash MM slash YYYY
AGE*
COUNTRY OF BIRTH*
OCCUPATION
STREET ADDRESS
ADDRESS*
Street Address City State / Province / Region ZIP / Postal Code
Is your postal address different?
- Yes
- No
POSTAL ADDRESS (IF DIFFERENT)
ADDRESS
Street Address City State / Province / Region ZIP / Postal Code
CONTACT DETAILS
HOME NUMBER
MOBILE*
EMAIL*
GUARDIAN/ NEXT OF KIN*
POST SURGICAL NEXT OF KIN CONTACT NAME*
POST SURGICAL NEXT OF KIN CONTACT PHONE*

Save and Continue Later

REFERRAL AND PRACTITIONER DETAILS
NAME
First
ADDRESS
Street Address
GENERAL MEDICAL PRACTITIONER (GP)
NAME
First
ADDRESS
Street Address
Are you a smoker?
- Yes
- No
GENERAL DENTIST
NAME
First
ADDRESS
Street Address
Do you have any other medical specialists involved with your care (e.g. Cardiologist etc.)?
- Yes
- No
IF YES PLEASE PROVIDE:
Name
First
Speciality

Save and Continue Later

MEDICARE DETAILS
CARD NO.*
REF NO (DIGIT NEXT TO YOUR NAME)*
EXPIRY DATE*
IS THE PATIENT ON A FAMILY MEDICARE CARD*
- Yes
- No
IF YES PLEASE PROVIDE:
ACCOUNT HOLDER NAME:*
First Last
ACCOUNT HOLDER DOB:*
DD slash MM slash YYYY
ACCOUNT HOLDER MEDICARE REFERENCE:*
PRIVATE HEALTH INSURANCE
FUND NAME
MEMBER NO.
Have you been with your health fund for more than 12 months?
- Yes
- No
Do you have hospital insurance
- Yes
- No
Do you have extra's cover
- Yes
- No
VETERAN AFFAIRS
CARD NO.
EXPIRY DATE
TAC/WORKCOVER
INSURER
CLAIM NO.
CLAIMS CONTACT

Save and Continue Later

HAVE YOU HAD OR CURRENTLY HAVE...
RHEUMATIC FEVER*
- Yes
- No
ARE YOU A DIABETIC ?*
- Yes
- No
TYPE*
- Type 1
- Type 2
HEART PROBLEMS*
- Yes
- No
- Angina
- Arrhythmia
- Valve replacement
- Stent
HEART MURMUR*
- Yes
- No
EPILEPSY*
- Yes
- No
KIDNEY DISEASE*
- Yes
- No
HEPATITIS*
- Yes
- No
ASTHMA*
- Yes
- No
HIGH BLOOD PRESSURE*
- Yes
- No
OSTEOPOROSIS*
- Yes
- No
STOMACH REFLUX/ULCER*
- Yes
- No
EXCESSIVE BLEEDING*
- Yes
- No
DO YOU HAVE ALLERGIES TO...
PENICILLIN*
- Yes
- No
ASPIRIN*
- Yes
- No
ANY OTHER MEDICATION?*
- Yes
- No
IF YES, PLEASE LIST THEM BELOW*
ANY FOODS?*
- Yes
- No
IF YES, PLEASE LIST THEM BELOW*
LATEX*
- Yes
- No
ELASTOPLAST OR TAPES*
- Yes
- No
ANY OTHER ALLERGIES?*
- Yes
- No
IF YES, PLEASE LIST THEM BELOW*
Have you recently ceased or are you currently on any weight loss drug (Ozempic, Wegovy etc )*
- Yes
- No
HAVE YOU EVER TAKEN ANY MEDICATIONS OR HAD REGULAR INJECTIONS FOR OSTEOPOROSIS OR BONE CONDITIONS/LESIONS?*
- Yes
- No
(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?*
- Yes
- No
ARE YOU TAKING THE ORAL CONTRACEPTIVE PILL?*
- Yes
- No
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? *
UPLOAD YOUR FILES
Drop files here or

Max. file size: 54 MB.
Consent to collect Information*
I agree to the privacy policy.
This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information you provide in the following ways:
1. Administrative purposes in running our medical practice.
2. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
3. Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you.

Save and Continue Later

Please ensure your information below is accurate and click 'submit' at the bottom of the form.
{all_fields}
After you click submit you will see a thank you notice if your submission was successful. Please don't leave the submission process until you have seen this notice.

Save and Continue Later

Consulting Locations

Pure Orthodontic Rooms, Level 4, 1070 Mt Alexander Rd, Essendon
Smile Council Orthodontic Rooms, Lev 1, 18 Scholar Drive, University Hill, Bundoora, Vic 3083
Camberwell Plastic Surgery Rooms, 402 Camberwell Road, Camberwell Vic 3214
Suit 3, Level 4, 10 Martin Street, Heidelberg Vic 3083

OPERATING LOCATIONS

Warringal Private Hospital
Northpark Private Hospital
Epworth Freemasons - Albert Street, East Melbourne

CONTACT US

(03) 7000 4000
rutherford@yarraomfs.com.au
yarraomfs.com.au
Suite 3, Level 4, 10 Martin Street, Heidelberg

Copyright 2018 Yarra Oral Maxillofacial Surgery | All Rights Reserved | Powered by practiceedge

Name
First Last
Email*
Phone*
Please upload your files (including referral and x-ray)*
Drop files here or

Max. file size: 20 MB.

Home
About
- About Nick Rutherford
- Appointment Policy
Post Operative Instructions
Hospital Admissions
Fee Structure
Hours
Contact