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;

First Name

Last Name

Title

Date of Birth

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)

Age

Mother / Guardian;

First Name

Last Name

Father / Guardian;

First Name

Last Name

Home Address

Address Line 1

Address Line 2

Suburb

State

Postcode

Best Phone/Mobile

Alternative Phone/Mobile

PERSON RESPONSIBLE FOR ACCOUNT;

Account-payer

Myself

Someone else

First Name

Last Name

Phone/Mobile

Address Line 1

Address Line 2

Suburb

State

Postcode

EMERGENCY CONTACT;

First Name

Last Name

Relationship to patient

Address Line 1

Address Line 2

Suburb

State

Postcode

Phone/Mobile

MEDICARE & HEALTH INSURANCE;

Medicare Number

Reference number on Medicare card

Name of Private Health Insurance

Member Number

Please specify level of cover;

Ancillary

Hospital

Period of Membership

Less than 12 months

More than 12 months

OTHER ELIGIBILITY;

Department of Veteran Affairs card number

Card Colour

Are you eligible for (please tick);

TAC

WorkCover

Claim Number

Company

Case Worker

GP;

Medical GP / Clinic

Medical GP / Clinic Address

Address Line 1

Address Line 2

Suburb

State

Postcode

Dentist;

Dentist / Clinic

Address

Address Line 1

Address Line 2

Suburb

State

Postcode

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):

First Name

Last Name

next-of-kin1-relationship

First Name

Last Name

next-of-kin2-relationship

Signature

Sign Here

Date

MEDICAL HISTORY QUESTIONNAIRE

Weight

Height

Have you ever had any heart related problems?

Yes

Please specify;

Have you ever had any breathing / lung related problems such as asthma, bronchitis, emphysema, bronchiectasis, sleep apnoea?

Yes

Please tick the breathing problems that apply to you;

Asthma

Bronchitis

Emphysema

Bronchiectasis

Sleep apnoea

Other

Are you a smoker?

Yes

How many do you smoke a day?

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

Please tick which ones;

Warfarin

Clopidogrel

Xarelto

Pradaxa

Aspirin

Other

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

Yes

Do you regularly experience anxiety?

Yes

Have you ever had a gag reflex?

Yes

Do you have diabetes?

Yes

Do you take insulin for your diabetes?

Yes

Blood pressure

Normal

High

Low

Do you take medication for osteoporosis?

Yes

Please tick which ones;

Fosamax

Zometa

Prolia

Other

Do you have any joint replacements?

Yes

Year inserted;

Have you ever been exposed to an infectious disease?

Yes

Please tick which ones apply;

Hepatitis B or C

HIV

Rheumatic fever

Scarlet fever

Other

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

Yes

Please specify the anaesthetic;

Are you pregnant or breast-feeding?

Pregnant

Breast-feeding

Do you have any allergies?

Yes

Please specify;

Please list any regular medications, including aspirin, contraceptives, herbals, vitamins

Do you have any other medical conditions not specified above?

Yes

Please specify;

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

Do you have ambulance cover?

Yes

Do you accept the associated ambulance costs in the unlikely event it is required?

Yes

Email, Phone, Fax

info@surfcoastoms.com.au

Ph: 03 5229 3200

Fax: 03 5229 9869

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