Patient registration form

PATIENT REGISTRATION

Title

First Name *

Surname *

Address *

Street address *

Suburb *

Contact numbers: Home

Work

Mobile *

Email *

Date of birth *

Age

Are you of Aboriginal or TSI descent? *

YesNo

Occupation

Medicare Card Number *

Expiry date

Patient number on Medicare Card *

DVA card number (If applicable)

Do you have private health insurance? *

YesNo

Do you have hospital cover?

YesNo

Do you have dental extras?

YesNo

Name of fund and level

Membership number

Patient reference number

Emergency contact/ Next of kin

Name

Relationship

Address

Contact numbers: Home

Work

Mobile

Person responsible for fees (FOR CHILDREN OR IF DIFFERENT TO PATIENT)

Name

Relationship

Address

Contact numbers: Home

Work

Mobile

Date of birth

Medicare Card Number

48 hours prior to your appointment time you will receive a confirmation text, are you happy to receive this service?

YesNo

How did you hear about the practice?

Have you visited our website?

YesNo

Privacy Statement / Consent for AI scribe

All staff at Oral & Facial Surgery Specialists respect the privacy of confidential information and seek to safeguard this information appropriately.

They will take all possible steps to regulate and protect the collection, use, security and disclosure of personal and sensitive information. Details of our privacy statement can be obtained from any of our consulting rooms.

We utilise a note taking tool called Heidi to accurately and efficiently capture the details of your consultation and the outcomes of your appointments. Heidi ensures that clinicians can focus more on the consultation and less on manual note taking, enhancing the quality of care you receive. Your consent is crucial for us to use this technology. Please understand that your information will be handled with the utmost care, and Heidi’s use is aimed solely at improving your health care experience.

Do you consent for the use of Heidi AI scribe during your consultation? *

YesNo

HEALTH QUESTIONNAIRE

Your medical history is important to us, please answer all question truthfully and to the best of your knowledge

to help plan your treatment and to avoid any unnecessary personal health risks.

Who is your usual medical doctor/GP ? Name of GP clinic?

GP clinic address

Street address

City

State

Postcode

Have you had any serious illnesses, operations or hospitalizations in the past? If so please state

Have you ever taken or are you currently taking anticoagulants - Iscover, Plavix, Warfarin, Asprin, Xarelto or Eliquis? *

YesNo

Have you ever had a problem with excessive bleeding or bruising following a tooth extraction? *

YesNo

Have you ever taken or are you currently taking steroids - cortisone, prednisolone or hydrocortisone? *

YesNo

Have you ever taken medication for osteoporosis, hypercalcaemia, Paget’s disease or other bone or calcium problems in the past 10 years? *

YesNo

Have you ever had heart surgery, valve replacement, hip or joint replacement or have a pacemaker? *

YesNo

Do you smoke or vape? *

YesNo

How much do you smoke/vape per day?

Do you consume alcohol regularly? *

YesNo

How many units of alcohol do you consume per week?

Do you have any allergies? *

YesNo

What are you allergic to?

Have you or a family member ever experienced a bad reaction to general anaesthesia? *

YesNo

List your previous surgeries (If applicable)

Please list your medications *

This section is for women only

Some medications used in Oral and Maxillofacial Surgery will cross the placental barrier and breast milk barrier. Some antibiotics may reduce the effectiveness of birth control pills. Some medications may affect the unborn foetus.

Are you pregnant?

YesNo

Are you breastfeeding?

YesNo

Signature of patient *

Draw signature|Type signatureClear

Date *