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  :  
MrMrsMsMissMasterDr
Given Names*:
Surname*:
Email Address*:
Phone Home:
Phone Work:
Home Address:
Are you in a Private Health Fund for Dental?  :  
YesNo
If yes, which one? :  
Are you covered by Veterans Affairs?  :  
YesNo
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?  
InternetWebsiteYellow PagesLocal DirectoriesFlyerFacebookGoogle AdsWalked PastPatient
If Patient, name
Have you ever had or do you have any of the following? (Please tick)
Anaemia
YesNo
Fainting
YesNo
Pacemaker
YesNo
Artificial Joints
YesNo
Glaucoma
YesNo
Radiation Therapy
YesNo
Asthma
YesNo
Heart Disease
YesNo
Chemotherapy
YesNo
Heart Murmur
YesNo
Rheumatic Fever
YesNo
Cancer
YesNo
Sinus Problems
YesNo
Hepatitis A, B, C (please select)
ABC
AIDS/HIV
YesNo
Heart Valve Replacement
YesNo
Latex Sensitivity
YesNo
Diabetes
YesNo
High Blood Pressure
YesNo
Smoking
YesNo
Tuberculosis
YesNo
Epilepsy
YesNo
Kidney Disease
YesNo
Liver Disease
YesNo
Excessive Bleeding
YesNo
Stroke
YesNo
Psychological Disorders
YesNo


Have you ever taken bisphosphonate medication as listed below?  
FosamaxBonefosDidronelDidrocalSkelidActonelArediaZometa


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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