Patient Registration Online Form - Oral and Facial Surgeons

Patient Registration

Title

First Name(Required)

Surname(Required)

Date of Birth(Required)

Email Address

Mobile Phone(Required)

Home Phone

Street Address(Required)

Street Address Line 2

City(Required)

State(Required)

Postcode(Required)

Country(Required)

Medicare Number(Required)

Number next to your name on card(Required)

Expiry - Month(Required)

Expiry - Year(Required)

Private Health Fund(Required)

Membership Number

Ref

Hospital Cover(Required)

Yes

Dental Cover(Required)

Yes

Vet Affairs No

Card Colour

Preferred Clinic Location(Required)

Brighton

Mornington

Ballarat

Secondary Contact Details (Next of Kin / Emergency / Family)

NOK Surname(Required)

NOK First Name(Required)

NOK Relationship(Required)

NOK Phone Number(Required)

NOK Date of Birth(Required)

NOK Email Address

NOK Street Address

NOK Street Address Line 2

NOK City

NOK State

NOK Postcode

NOK Country

Person responsible for fees

Self

Others

Referrer Details

Referring Specialist Clinic Name(Required)

Referring Specialist Name

Referrer Phone Number

Usual Dentist Details

Usual Dentist Clinic Name(Required)

Usual Dentist Name(Required)

USUAL DENTIST DETAILS

Name of person responsible for fees

DO YOU HAVE ANY OF THE FOLLOWING?(Required)

Are you vaccinated against COVID 19?(Required)

1 Dose

2 Doses

3+ Doses

Have you tested positive to COVID-19?(Required)

Yes

If yes, please specify the date(s) below:

List all major operations or other serious illnesses and year

List your current medications & dosage

Do you have any allergies?(Required)

Yes

If yes, please list allergies below:

List any problems with general anaesthetic

Height (cm)

Weight (kg)

Do you have any relation to a previous or current patient of the surgery?

Yes

Current patient name

Upload Referral

Drop files here or

Max. file size: 3 MB, Max. files: 10.

Upload Radiographs

Drop files here or

Max. file size: 3 MB, Max. files: 10.

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:

Administrative purposes in running our medical practice.
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
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.

Signature(Required)

Date

Patient Registration Form