Patient Registration Form "*" indicates required fields 1Section 1 of 32Section 2 of 33Section 3 of 3 Patient DetailsName* Dr.MissMasterMr.Mrs.Ms.Prof.Rev. Title First Last Birthdatedd/mm/yyyyHome phone numberMobile phone numberEmail* Postal Address* Street Address City State Postcode Private Hospital Cover* Yes No Fund NameFund Membership #Reference #Dental Cover* Yes No DVA* Yes No Department of Veteran AffairsDVA # Medical DetailsMedical GP*Medical Practice*Approx heightApprox weightMedical History Anemia Anxiety Asthma Arthiritis Bleeding Disorders or Excessive Bleeding Bone Disease Cancer Cholesterol Congestive Heart Failure Depression Diabetes Drug Use (recreational) Eczema-Hives Epilepsy or Seizures Heart Disease Heart Valve Surgery Hepatitis Heart Blockage High Blood Pressure HIV/AIDS Immune Disorders Kidney Disease Liver Disease Lung Disease Mental Health or Psychiatric Condition Osteoporosis Pacemaker Prosthetic/Joint Replacement Radiation Therapy Steroid Therapy Stroke Thyroid Disease Nil Pregnant* Yes No OtherAllergiesPlease list any allergiesMedicationsPlease list all medications including over the counter drugs or vitaminsBone Disorders*Have you ever taken any medication (or injections) for any bone disorders? Yes No Smoking*Do you smoke or take any recreational drugs? Yes No Qty SmokesHow many per day?Alcohol*Do you drink alcohol? Yes No Qty DrinksHow many per week? Secondary Contact DetailsNext of kin / Emergency / FamilyContact Name* First Last Relationship*Contact Phone Number*Person Responsible for Fees* Self Others ConsentConsent for Services* I understand that the clinic will collect my information for the primary purpose of providing safe health care Collecting of information refers to your personal information, medical history, relevant images, x-rays and any other information pertaining to your care at the Ballarat Wisdom Tooth and Implant Centre Personal information such as my name, address and health insurance details are used for the purpose of addressing accounts and sending relevant correspondence, as well as processing payments and writing to me about my services and any issues affecting my heath care I also understand that payment on the day is required upon completion of my appointment. Procedures completed at the local day procedure centre or hospital require pre-payment, which can be later claimed for by my respective private health fund or insuring party. Form completed by* Patient Carer Carer NameDigital SignatureType your name as acknowledgement of a digital signatureDate DD slash MM slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Δ
