For patients

Confidential patient registration form

Patient Details

Disclosure authorisation

Medical History

Welcome to our practice. For our confidential records and to assist in determining your treatment, please answer the following questions as accurately as possible.

Fees are the responsibility of the patient, parent or guardian. Consultations and surgical procedures in the rooms are required to be paid at the time of your visit.

Please either download and return our Confidential Patient Registration Form or submit your information securely online below:

Patient details

Title

Given Name

Surname

Date of Birth

You can click the Month and Year labels at the top of the calendar to quickly change the date.

Home Address

Suburb

Postcode

Landline Number

Mobile Number

Email Address

Account Responsibility

Person responsible for account:

Myself

Someone Else

Home Address

Suburb

Postcode

Phone Number

Email Address

Emergency Contact

Title

Given Name

Surname

Relationship to patient

Home Address

Suburb

Postcode

Phone Number

Medicare and private health insurance

Medicare Number

Reference No.

Do you have private health insurance?

Yes

Other Eligibility

Department of Veteran Affairs card no.

Card Colour

Are you eligible for:

TAC

WorkCover

Medical GP / Clinic contact details

Doctor's Name

Clinic Name

Address

Suburb

Postcode

Phone Number

Dentist / Clinic contact details

Dentist's Name

Clinic Name

Address

Suburb

Postcode

Phone Number

Disclosure authorisation

We respect your privacy and will not disclose any information to anyone without your prior approval unless it is clinicians and hospitals directly involved with your treatment / care.

I give authorisation for disclosure of my records or treatment with the following next of kin(s):

Person 1

Given Name

Surname

Relationship

Person 2

Given Name

Surname

Relationship

Authorisation

Sign Here

I confirm that the provided information is true and correct

Clear Signature

Date

How did you hear about us?

Medical History

How much do you weigh (kg)?

How tall are you (cm)?

(This information guides fitness for procedure decisions).

Have you had Covid-19?

Yes

Have you received all the required Covid-19 vaccinations?

Yes

Have you ever had any heart related problems (eg. AMI, Stents, Valve Replacement)?

Yes

Have you ever had any breathing / lung related problems?

Yes

Are you a smoker?

Yes

Do you have any bleeding or clotting disorders?

Yes

Have you ever had prolonged bleeding from dental procedures?

Yes

Do you take any blood thinners?

Yes

Do you get acid reflux into your mouth or have you had stomach ulcers?

Yes

Do you regularly experience anxiety?

Yes

(This background might suggest the appropriate treatment format).

During dental procedures, do you have an issue with a gag reflex?

Yes

Do you have diabetes?

Yes

Blood Pressure

Low

Normal

High

Do you take medication for osteoporosis?

Yes

Do you have any joint replacements?

Yes

Have you ever been exposed to an infectious disease?

Yes

Have you ever had a problem with any type of anaesthetic?

Yes

Are you pregnant or breast feeding?

Yes

Do you have any allergies (eg. medication, latex, food)?

Yes

Do you take any regular medications (eg. aspirin, contraceptives, herbal, vitamins)?

Yes

Do you have any other medical conditions not specified above?

Yes

Rarely, ambulance transfer to a nearby hospital may be required (eg. for anaphylaxis). Do you have ambulance cover?

Yes

Get in touch

Please fill out the form below to book a consultation at Precision OMS’s Geelong offices.

Full Name

Email Address

Phone Number

Message

By submitting this form you are agreeing to the Privacy Policy

Confidential patient registration form

Patient details

Account Responsibility

Emergency Contact

Medicare and private health insurance

Other Eligibility

Medical GP / Clinic contact details

Dentist / Clinic contact details

Disclosure authorisation

Person 1

Person 2

Authorisation

Medical History

Your form has been successfully submitted

Get in touch