Confidential Patient Registration Form

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.

PATIENT;

Directly type in your date of birth, or use the date-picker by clicking the box. Save time in the datepicker by typing the year first (no need to press Enter)

Mother / Guardian;

Father / Guardian;


PERSON RESPONSIBLE FOR ACCOUNT;


EMERGENCY CONTACT;


MEDICARE & HEALTH INSURANCE;

Please specify level of cover;


OTHER ELIGIBILITY;


GP;


Dentist;


DISCLOSURE AUTHORISATION;

Surf Coast OMS 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, {inputs.names.first_name} {inputs.names.last_name}, give authorisation for disclosure of my records or treatments with the following next of kin(s):

1.

2.

Sign Here

MEDICAL HISTORY QUESTIONNAIRE


Rarely, ambulance transfer to a nearby hospital may be required (eg. for anaphylaxis). 

ADDRESS

16 Myers Street,
Geelong,
Vic  3220

(find us)

OPENING HOURS

Mon-Fri: 9am to 5pm

Appointments outside of these normal hours may be available on some days