For patients

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.

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

lf the patient is under 18 years of age, please specify:

Mother / Guardian

Given Name
Surname

Father / Guardian

Given Name
Surname

Parent / Guardian Contact Details

Home Address
Suburb
Postcode
Phone Number
Mobile Phone
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 No

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

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
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