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 Date of Birth:

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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 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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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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Pension Card No.

HealthCare Card No.

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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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Other:

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How may we contact you?

SMS

Phone

Mail

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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.

I consent to this specialist practice contacting my referring doctor, GP and other external health care providers involved in my ongoing care for the purpose of obtaining clinical information to assist in my ongoing management.

I consent to this specialist practice releasing my clinical information to my referring doctor, GP and other external health care providers involved in my ongoing care for the purpose of assisting in my ongoing management.

I have read the privacy information provided. I understand that my information will be held in the consulting rooms and I am happy for reports and copies on my condition to be sent to my referring Dentist/Doctor and health professionals involved in my care.

I would not like information given to

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Please specify:

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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)

Please specify:

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Please specify:

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Please specify:

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Please specify:

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Please specify:

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Please specify:

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Please specify:

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Please specify:

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If yes, when is your due date?

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If yes, please specify how many per day:

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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.

I understand that I am financially responsible for all accounts (with the exception of Third Party claims).

I acknowledge that I give consent regarding the presence of student dentist and doctors before, during and after my surgery or visit. I understand that the student will be able to observe, discuss and access clinical information. I hereby give my consent to be observed by students for the purpose of teaching, research and/or advancing clinical care. The student will not perform any surgery or procedures.

Photography before and after photos are part of my medical record. Occasionally, your surgeon may use these photos, with reasonable identity protection, for patient education and online.

This information represents my medical history to the best of my knowledge. Any changes will be advised at subsequent appointments.

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Online Photography Opt-out

Patient Education Photography Opt-out

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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)

Upload

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Submit

Patients

Download Patient Registration Form (PDF)

PATIENT REGISTRATION FORM (Confidential)

Referring Doctor/Dentist:

Patient Information

Medicare & Healthfund Details

Practitioner Details

In Case of Emergency

Privacy Policy

General Health Questions

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.

Upload X-Rays (Optional)

Schedule a Consultation

Burwood Rooms

Westmead Rooms

Burwood Rooms

Westmead Rooms