NEW PATIENT INFORMATION FORM
To provide you with the highest level of care, please complete this Registration and Health History Questionnaire.
Please note that all information on this questionnaire will remain confidential and will form part of your health record.
Personal Details
Surname _______________Given Names _______________Date of Birth ________
Occupation ____________________Title (Mr, Mrs, Miss, Ms, Dr, Other) ___________
Address ________________________________________________________________________________
Phone Home _____________________ Work __________________ Mobile __________________________
Email Address ___________________________
Would you like appointment reminders via Email Yes / No and or SMS? Yes / No
What is your preference for communication from our practice? (please circle)
home phone
work phone
mobile phone
If under 14 years old:
Guardian Name _____________________________________________ Phone ______________________________
Address____________________________________________________________________________________________
Is another member of your family a patient at our practice? (please give details)
___________________________________________________________________________________________________
Emergency Contact
Name and relationship __________________________________________________Phone______________________________
Address_________________________________________________________________________________________________________
Next of Kin Details
Name and relationship __________________________________________________Phone______________________________
Address_________________________________________________________________________________________________________
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Medicare Details
Card Number:
Reference Number on Card:
Expiry Date:
(Please show Medicare card with this form)
Commonwealth Concession Card Details
Please circle the type of card below
Pension
Health Care
Card number:
Seniors
Veterans Affairs
Expiry Date:
_____
You must have a valid concession card at time of appointment to be bulk billed.
Are you Aboriginal or Torres Strait Islander? (please circle) Yes / No
Health Insurance Details
Health Fund
__________________ Type of Cover________________________
Medical History
Where are your medical records currently kept?
If you would like to transfer your medical records to this practice please fill in an
authority to transfer medical records form.
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Medical History
The information provided in this section is necessary for the provision of safe and efficient dental care.
Have you been under the care of a medical doctor during the past two (2) years?
Yes / No
If yes, please provide details
__________________________________________________________________________________
__________________________________________________________________________________
Doctor’s Name ____________________________________ Phone _____________________
Address
__________________________________________________________________________________
Are you taking any tablets or medicines at present? Yes / No
If yes, please list
__________________________________________________________________________________
__________________________________________________________________________________
Have you ceased any medications in the past two (2) years? Yes / No
If yes, please list
__________________________________________________________________________________
__________________________________________________________________________________
Have you ever had an allergic (or adverse) reaction to any medication or substance
(including latex)? Yes / No
If yes, please list
__________________________________________________________________________________
__________________________________________________________________________________
Have you ever had any unusual or adverse reactions to local or general
anaesthetic? Yes / No
If yes, please provide details
__________________________________________________________________________________
Do you smoke or have smoked in the past ?
Yes / No
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Please indicate if you currently have, or have had in the past, any of the following:
Please circle Yes or No
Heart condition
(surgery,disease,
attack)
Yes
No
Kidney Disease
Yes
No
Yes
No
Radiation Therapy
If yes, region
__________________
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Angina/Chest Pain
Stroke
Yes
No
Hepatitis or other liver
disease
Yes
No
Anaemia/Leukemia/ot
her
blood condition
Transplanted organ
or marrow
Excessive Bleeding
Yes
No
Yes
No
Yes
No
No
Contact with
HIV/AIDS virus
Yes
No
Chemotherapy
Yes
No
Cardiac Pacemaker
Tuberculosis
Yes
No
Artificial Heart Valve
Asthma
Yes
No
Other heart valve
condition
Bronchitis/Emphysema
/Other
lung condition
Yes
No
Heart Murmur
Yes
No
Diabetes
Yes
No
Yes
No
Thyroid Condition
Yes
No
Yes
No
Steroid Therapy
Epilepsy/Seizures
Yes
No
Neurological Condition
Yes
No
Other Cancer
Yes
No
Yes
No
Yes
No
No
No
Yes
No
Glaucoma or
Cataracts
Cold Sores
Yes
Yes
Psychological
Condition
Kidney Disease
Yes
No
Yes
No
Sinus problems
Yes
No
Pregnant
Yes
No
Rheumatic Fever
High Blood Pressure
Low Blood Pressure
Artificial joint
replacement
Stomach/Digestive
Condition
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Consent for Services
1. I _____________________________, have answered all questions to the best of my
knowledge, and agree to notify the surgery of any changes to my health or
medication. Where essential to the provision of optimal care, I give consent for
authorised members of this practice to seek further health history information from
the relevant health care provider. I understand that my health information may be
disclosed to authorised personnel where necessary for the provision of optimum
care.
2. I hereby authorise the Doctor or designated staff to use all necessary diagnostic
aids deemed appropriate by the Doctor to make a thorough diagnosis.
3. Upon such diagnosis, I authorise the Doctor to perform all treatment mutually
agreed upon by me, and to employ such assistance as required to provide proper
care.
4. I will be responsible for payment of all services rendered on my behalf and on
behalf of my dependents. I understand that payment is due at the time of service
and a $5 fee will apply if payment is not made on the day of consultation.
5. I understand that this practice requires a minimum of 24 hours notice if I need to
cancel my scheduled appointment. If I do not give 24 hours notice of cancellation,
a fee will apply as per the practice’s Cancellation Policy.
Patient/Guardian Signature
__________________________________________________________________
Date __________________
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