Patient Registration Form

Personal details

Title

First Name *

Surname *

Date of Birth *

Preferred Name

Gender

Address *

Occupation

Mobile *

Email

Medicare Number *

Ref *

Professional Contacts

Referring Dentist / Doctor

Name

Practice Name & Address

General Practitioner

Name

Address

Next of Kin

Name

Relationship to you

Tel

Reason for referral

What is the reason for your referral? *

Health Questionnaire

Please specify what other health problems you may have?

Smoking

Current smokerEx-smokerNever

DetailsHow many cigarettes per day? for how long? When did you quit?

Alcohol drinkingDrinks/week

Medications and Allergies

Prescription Medications *List all your regular medications, if you are not taking any, please type "None"

Over the Counter and recreational drugsInclude herbal and vitamins

Do you have allergies (drug, food, material)?

Agreement and signature

Privacy agreement - To comply with the Privacy Laws (Privacy Act Amendments – Private Sector – Act 2000) your agreement to the following statement is required:

I agree to allow my treating doctor access to all relevant information regarding my medical and dental conditions. I understand that the doctor may be required to forward information about my medical condition or history to other health care providers. I understand that to provide the highest medical care, my clinical records may be accessed or reviewed by staff in this practice.

Name

Date

Signed

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