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Patient Registration Form

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    DR SAM VERCO

    Oral and Maxillofacial Surgeon

    BDS(Adel) MBBS(Melb) Grad Dip OMS(Melb) FRACDS (OMS)

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    DR BRENT WOODS

    Oral and Maxillofacial Surgeon

    BDS(Adel) MBBS(Melb) Grad Dip OMS(Melb) FRACDS (OMS)

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    PRINT / DOWNLOAD

    Patient Registration Form

Title

Title, if other

First Name

Surname

Street Address

Suburb

State & Postcode

Date of Birth

Email Address

Home Phone

Work Phone

Mobile

Medicare Number

Number next to your name on card

Private Health Fund

Membership Number

Ref

Hospital Cover

YesNo

Dental Cover

YesNo

Vet Affairs No

Card Color

Health Care / Pension Card No

Usual GP

GP Contact No

Usual GP Address

Dentist

Address

Occupation

Name of person responsible for fees (or self)

Emergency Contact

Relationship

Mobile

Do you have any of the following?

If Pregnant, how many weeks?

Blood Pressure, High or Low?

List Allergies

List and major operations or other serious illnesses and year

List your current medications & dossage

List any problems with general anaesthetic

CONSENT TO COLLECT PATIENT INFORMATION
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.

*I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me.
*I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld.
*I understand that if my information is to be used for any purpose other than the above, my consent will be sought.
*I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify the practice.

Your Signature

Date

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