Patients

PATIENT REGISTRATION FORM (Confidential)

Referring Doctor/Dentist:

First Name
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Last Name:
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Patient Information

Date:
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Your Given Name:
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Your Middle Name:
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Your Surname:
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Your Preferred Name:
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Your Title:
  • Dr.
  • Mr.
  • Mrs.
  • Ms.
  • Miss.
  • Mst.
  • Other
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Your Date of Birth:
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Your Gender
  • Male
  • Female
  • Other
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Your Occupation:
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Your Address:
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Your Postcode:
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Your City:
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Your Country:
  • Åland Islands
  • Afghanistan
  • Albania
  • Algeria
  • American Samoa (US)
  • Andorra
  • Angola
  • Antigua and Barbuda
  • Argentina
  • Armenia
  • Australia
  • Austria
  • Azerbaijan
  • Bahamas
  • Bahrain
  • Bangladesh
  • Barbados
  • Belarus
  • Belgium
  • Belize
  • Benin
  • Bermuda (UK)
  • Bhutan
  • Bolivia
  • Bosnia and Herzegovina
  • Botswana
  • Brazil
  • Brunei
  • Bulgaria
  • Burkina Faso
  • Burma (Myanmar)
  • Burundi
  • Cambodia
  • Cameroon
  • Canada
  • Cape Verde
  • Central African Republic
  • Chad
  • Chile
  • China
  • Colombia
  • Comoros
  • Congo, Democratic Republic of the
  • Congo, Republic of the
  • Cook Islands (NZ)
  • Costa Rica
  • Croatia
  • Cuba
  • Cyprus
  • Czech Republic
  • Denmark
  • Djibouti
  • Dominica
  • Dominican Republic
  • East Timor (Timor-Leste)
  • Ecuador
  • Egypt
  • El Salvador
  • Equatorial Guinea
  • Eritrea
  • Estonia
  • Ethiopia
  • Falkland Islands (UK)
  • Faroe Islands (Denmark)
  • Fiji
  • Finland
  • France
  • French Guiana
  • French Polynesia (France)
  • Gabon
  • Gambia
  • Georgia
  • Germany
  • Ghana
  • Gibraltar (UK)
  • Greece
  • Greenland (Denmark)
  • Grenada
  • Guam (US)
  • Guatemala
  • Guernsey (UK)
  • Guinea
  • Guinea-Bissau
  • Guyana
  • Haiti
  • Honduras
  • Hong Kong (China)
  • Hungary
  • Iceland
  • India
  • Indonesia
  • Iran
  • Iraq
  • Ireland
  • Isle of Man (UK)
  • Israel
  • Italy
  • Ivory Coast
  • Jamaica
  • Japan
  • Jersey (UK)
  • Jordan
  • Kazakhstan
  • Kenya
  • Kiribati
  • Korea, North
  • Korea, South
  • Kosovo
  • Kuwait
  • Kyrgyzstan
  • Laos
  • Latvia
  • Lebanon
  • Lesotho
  • Liberia
  • Libya
  • Liechtenstein
  • Lithuania
  • Luxembourg
  • Macau (China)
  • Macedonia
  • Madagascar
  • Malawi
  • Malaysia
  • Maldives
  • Mali
  • Malta
  • Marshall Islands
  • Mauritania
  • Mauritius
  • Mayotte (France)
  • Mexico
  • Micronesia, Federated States of
  • Moldova
  • Monaco
  • Mongolia
  • Montenegro
  • Morocco
  • Mozambique
  • Namibia
  • Nauru
  • Nepal
  • Netherlands
  • New Caledonia (France)
  • New Zealand
  • Nicaragua
  • Niger
  • Nigeria
  • Niue (NZ)
  • Norfolk Island (Australia)
  • Northern Mariana Islands (US)
  • Norway
  • Oman
  • Pakistan
  • Palau
  • Palestinian territories
  • Panama
  • Papua New Guinea
  • Paraguay
  • Peru
  • Philippines
  • Pitcairn Islands (UK)
  • Poland
  • Portugal
  • Qatar
  • Réunion (France)
  • Romania
  • Russian Federation
  • Rwanda
  • São Tomé and Príncipe
  • Saint Helena, Ascension and Tristan da Cunha (UK)
  • Saint Kitts and Nevis
  • Saint Lucia
  • Saint Pierre and Miquelon (France)
  • Saint Vincent and the Grenadines
  • Samoa
  • San Marino
  • Saudi Arabia
  • Senegal
  • Serbia
  • Seychelles
  • Sierra Leone
  • Singapore
  • Slovakia
  • Slovenia
  • Solomon Islands
  • Somalia
  • South Africa
  • South Sudan
  • Spain
  • Sri Lanka
  • Sudan
  • Suriname
  • Svalbard and Jan Mayen (Norway)
  • Swaziland
  • Sweden
  • Switzerland
  • Syria
  • Taiwan
  • Tajikistan
  • Tanzania
  • Thailand
  • Togo
  • Tokelau (NZ)
  • Tonga
  • Trinidad and Tobago
  • Tunisia
  • Turkey
  • Turkmenistan
  • Tuvalu
  • Uganda
  • Ukraine
  • United Arab Emirates
  • United Kingdom
  • United States
  • Uruguay
  • Uzbekistan
  • Vanuatu
  • Vatican City
  • Venezuela
  • Vietnam
  • Wallis and Futuna (France)
  • Western Sahara
  • Yemen
  • Zambia
  • Zimbabwe
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Your Home Phone:
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Your Work Phone:
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Your Mobile Phone:
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Your Email Address:
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Medicare & Healthfund Details

Health Fund Number:
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Health Fund ID:
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Health Fund Name:
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Dental Cover:
  • Yes
  • No
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Hospital Cover:
  • Yes
  • No
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Medicare Number:
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Medicare Card Ref:
(Number next to your name on the card)
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Expiry Date:
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Card Number
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Expiry Date:
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Practitioner Details

General Dentist Name:
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General Dentist Address:
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General Dentist Suburb:
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General Dentist Postcode:
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General Medical Practitioner:
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General Practitioner Address:
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General Medical Practitioner Suburb:
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General Medical Practitioner Postcode:
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In Case of Emergency

Emergency Contact Name:
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Relationship to Patient:
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Emergency Contact No:
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How did you hear about our practice?
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Other:
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How may we contact you?
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Have you ever been treated by an Orthodontist? If yes, who?
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Privacy Policy

Your medical records are confidential. No results will be given over the telephone. Results will only be given to third party medical practitioners if the consents below have been obtained. It is a policy of this practice to maintain security of personal health information at all times and to ensure this information is only available to authorised members of staff.
Privacy Policy Acknowledgements:
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Print Name (Patient/Parent/Guardian):
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Signature:
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Date:
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General Health Questions

(Please complete the following questions to assist us in ensuring we provide you with the best care possible. All information given will be treated with the utmost confidentiality)
Do you presently have, or had in the past, any of the following conditions:
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Do you have any allergies?
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  • Yes
  • No
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Are you currently taking medication including any natural product, herbal supplement or homeopathic remedy?
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  • Yes
  • No
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Have you had any radiotherapy treatment for cancer of the head or neck area?
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  • Yes
  • No
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Have you ever had excessive bleeding following a cut, extraction, or surgery?
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  • Yes
  • No
Please Select
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Have you been hospitalised for any reason including general anaesthetics?
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  • Yes
  • No
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Any other medical problems?
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  • Yes
  • No
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Have you had or have Osteoporosis, bone cancer, Paget’s disease or multiple myeloma?
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  • Yes
  • No
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Have you ever taken Denosumab (Prolia, Xgeva), Alendronate (Fosamax, Fosamax Plus, Alendro, Dronalen), Risedronate (Actonel, Actonel Combi), Tiludronate (Skelid), Pamidronate (Aredia, Pamisol), Zoledronate (Zometa, Aclasta, Etridonate, Didrocal)?
  • Please Select
  • Yes
  • No
Please Select
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Are you pregnant?
(Females only)
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  • Yes
  • No
  • N/A
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If yes, when is your due date?
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Do you smoke?
  • Please Select
  • Yes
  • No
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If yes, please specify how many per day:
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Do you drink alcohol?
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  • Yes
  • No
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If yes, please specify how many per day:
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This is an informed-consent document and is important that you read this information carefully and completely. Please select each statement, indicating that you have read the information and is true to the best of your knowledge.

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Print Name (Patient/Parent/Guardian)
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Signature
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Date:
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Upload X-Rays (Optional)

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Schedule a Consultation

Wisdom tooth removal is often necessary for optimal oral health. To find out if this type of treatment can reduce your risk for cavities, periodontal disease, and other issues, schedule a consultation with Dr Zoud. Contact Wisdom Specialist Centre online or call us at 02 8021-2728.

Burwood Rooms

Shop 1/8 Burwood Rd
Burwood NSW 2134
P: (02) 8021 2728
F: (02) 8021 2723
info@wisdomcentre.com.au

    Westmead Rooms

    Suite 40, Daher Centre, 163 – 171
    Hawkesbury Road Westmead,
    NSW 2145
    P: (02) 9633 4552
    F: (02) 9893 8801
    reception@westmeadomfs.com.au