Patient Registration Form

PATIENT DETAILS

Title *

First name *

Middle name

Last name *

Preferred name

Gender *

Date of birth *

Age *

CONTACT DETAILS

Address *

Suburb *

State *

Postcode *

Email

Home phone

Mobile phone

Work phone

How may we contact you?

How did you hear about our practice?

MEDICARE AND DVA

Do you have a Medicare Card? *

YesNo

Medicare card number (red in image) *

Reference number (green in image) *

Medicare expiry (blue in image) *

Do you have a DVA Gold Card? *

YesNo

Veterans File Number *

PRIVATE HEALTH INSURANCE

Do you have a private insurance? *

YesNo

Health fund name *

Membership number *

Reference number (number infront of your name) *

What type of private health cover do you have? *

EMERGENCY CONTACT DETAILS

Name *

Contact number *

Specify

PRACTITIONER DETAILS

Referring doctor/ dentist

General dentist name

Address

Phone number

General medical practitioner name

Address

Phone number

Specialist Name

Address

Phone number

MEDICAL HISTORY

Do you have any of the following conditions?

High blood pressure

Heart attack

Coronary stents

Heart valve replacement

Atrial fibrillation

Rheumatic fever

Pacemaker

High chloesterol

Stroke/TIA

Epilepsy

Asthma

Bronchitis

Tuberculosis

Sleep apnoea

Thyroid disorder

Thyroid Disorder Type

HyperthyroidismHypothyroidism

Kidney disease

Liver disease

Hepatitis

HIV

Anaemia

Cancer past/present

Reflux (GORD, GERD)

Eating disorder

Arthritis

Depression/Anxiety

Other mental health condition

Jaw muscle pain (TMD)

Heart murmur

Neck/shoulder pain

Other

None of the above

Please specify

Do you have diabetes? *

YesNo

Which type do you have?

What medications do you take?

Have you had or have any of the following?

OsteoporosisBone cancerPaget's diseaseMultiple myeloma?

Have you ever taken any of the following medications?

Denosumab (Prolia, Xgeva)Alendronate (Fosamax, Fosamax Plus, Alendro, Dronalen)Risedronate (Actonel, Actonel Combi)Tiludronate (Skelid)Pamidronate (Aredia, Pamisol)Zoledronate (Zometa, Aclasta, Etridonate, Didrocal)

When was your last Prolia injection? *

Do you take any regular prescribed medications? *

Please advise the details of the medication name, dose and frequency of each below: *

Do you take any supplements, vitamins, herbal medications or over the counter medications? *

Please advise the supplement/vitamin name, dose and frequency for each below: *

Do you have any allergies *

YesNo

Please specify your allergy and reaction: *

Have you ever had a reaction to local anaesthetic?

Please describe your reaction below:

Have you ever had a reaction to general anaesthetic?

Please describe your reaction below?

Have you had any previous joint replacement surgery e.g. shoulder, hip, knee?

Please advise which joint was replaced and when surgery was performed?

Have you had any other previous surgery?

Please advise the type of surgery and when surgery was performed:

Have you had any radiotherapy treatment for cancer of the head or neck area?

When and where did you have radiotherapy treatment?

Have you had excessive bleeding following a cut,extraction, or surgery? *

Did you need to go to hospital to stop the bleeding?

Are you pregnant (Female patients)?

When is your due date?

Do you smoke? *

What do you smoke?

How many per day?

Do you drink alcohol? *

How many per day? *

What is you occupation?

Please upload your referral letter.

Browse

Please upload any Xrays you may have.

Browse

PRIVACY POLICY

We collect your personal information for the primary purpose of providing services to you. Your medical records are confidential. No results will be given over the telephone. Results will only be given to third-party medical practitioners if the below consents have been obtained. It is the policy of this practice to maintain the security of personal health information at all times and to ensure this information is only available to authorised members of staff. Please view our full Privacy Policy, a printed copy of our full Privacy Policy is available on request from our staff.

I consent to Wisdom Specialist Centre contacting my referring doctor, GP, and other external health care providers involved in my ongoing care for the purpose of obtaining clinical information to assist in my ongoing management.
*

I have read the privacy information provided. I understand that my information will be held in the consulting rooms and I am happy for reports and copies on my condition to be sent to my referring Dentist/Doctor and health professionals involved in my care. *

I consent to upload relevant health records, corrospondence to My Health Record.

Please do not share my information with:

CONSENT

This is an informed-consent document and is important that you read this information carefully and completely. Please tick next to each statement, indicating that you have read the information and is true to the best of your knowledge.

I understand that I am financially responsible for all accounts (with the exception of Third Party claims). *

This information represents my medical history to the best of my knowledge. Any changes will be advised at subsequent appointments. *

Clinical photographs are part of my medical record. Occasionally, your surgeon may take clinical photographs as part of your clinical assessment and records

Clinical photographs with reasonable identity protection, may be used for patient education and online posting.

SIGNATURE

Patient/ Guardian Signature *

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Today's Date

Name *

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