Patient registration form

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Please complete the following confidential questionnaire, which will assists us in providing you with quality dental care.

Select Practice* (required):
Please Select  :  
Mr Mrs Ms Miss Master Dr 
Given Names*:
Surname*:
Email Address*:
Phone Home:
Phone Work:
Home Address:
Are you in a Private Health Fund for Dental?  :  
Yes No 
If yes, which one? :  
Are you covered by Veterans Affairs?  :  
Yes No 
If yes, card number?:  
Medicare Card No.:
Date Of Birth:
Occupation:
Parent/Guardian names if under the age of 16:
How did you hear about us?  
Internet Website Yellow Pages Local Directories Flyer Facebook Google Ads Walked Past Patient 
If Patient, name
Have you ever had or do you have any of the following? (Please tick)
Anaemia
Yes No 

Fainting
Yes No 

Pacemaker
Yes No 

Artificial Joints
Yes No 

Glaucoma
Yes No 

Radiation Therapy
Yes No 

Asthma
Yes No 

Heart Disease
Yes No 

Chemotherapy
Yes No 

Heart Murmur
Yes No 

Rheumatic Fever
Yes No 

Cancer
Yes No 

Sinus Problems
Yes No 

Hepatitis A, B, C (please select)
A B C 

AIDS/HIV
Yes No 

Heart Valve Replacement
Yes No 

Latex Sensitivity
Yes No 

Diabetes
Yes No 

High Blood Pressure
Yes No 

Smoking
Yes No 

Tuberculosis
Yes No 

Epilepsy
Yes No 

Kidney Disease
Yes No 

Liver Disease
Yes No 

Excessive Bleeding
Yes No 

Stroke
Yes No 

Psychological Disorders
Yes No 


Have you ever taken bisphosphonate medication as listed below?  
Fosamax Bonefos Didronel Didrocal Skelid Actonel Aredia Zometa 


Are you allergic to any medications? List if any:
Please list all medications you are currently taking:
Have you been a patient in the hospital in last 4-5 years? If so, why and when?
Do you have any artificial joints or heart valves? If so, what and when did you have?
Do you have any heart conditions? If so, what?
Do you have any other disease or condition not mention on this form?
Do you smoke? (If so, how many per day?)
Has anyone ever told you that you snore? After 7 hours of sleep, do you feel refreshed?
Are you pregnant? If so, how many weeks? Nursing?
GP's Name and location:
Consent for treatment
1. I hereby authorise the dentist or designated team to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.
2. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by myself and to employ such assistance as required to proper care.
3. I agree to the use of anaesthetics and other medication as necessary. I fully understand that using anaesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
4. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of service unless other arrangements have been made.
5. I authorise that this data may be reviewed by team members of the dental practice.


Signature:
Date of Signature:

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