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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