Patient Registration — Tasmanian Oral and Maxillofacial Implant Surgery (Copy)

Medical care requires full knowledge of patient health information by al member of the medical team. To ensure quality and continuity of patient care, patient's health information must be shared with other healthcare providers/diagnostic facilities from time to time. Some information about patients is provided to Medicare and Private Health Fund, if relevant, for legal and medical rebate reasons. fI you have any concerns, please ask to speak to the Practice Manager

Name *

First Name

Last Name

Date of Birth *

YYYY

Email *

Phone *

(###)

###

####

Home Address

Country of Birth

Preferred Language

Your Occupation

Emergency Contact Person *

First Name

Last Name

General Practitioner's Name

First Name

Last Name

Name of Practice / Clinic

General Dentist's Name

First Name

Last Name

Name of Dental Practice

Medicare Number *

Reference Number *

Medicare Expiry Date *

Pension Card or Health Care Number

Expiry Date

Complete this section if you have private, overseas or DVA health cover

Private Health Fund Name?

Member Number *

Have you had hospital cover for over 12 months?

Yes

If yes is your level of cover...

Bronze

Silver

Gold

Overseas Health Fund Name?

Overseas Member Number *

Date Joined (month / year)

DVA Number *

DVA Expiry Date *

Colour of card

Gold

White

Orange

Workers compensation claim

Yes

If yes please contact Practice Manager

Allergies to medications or any bad reactions

If you take blood thinner medication please list below.

If you take diabetes medication or insulin therapy please list below

Have you ever had any of the following conditions?

Please select all that apply

Rheumatic Fever

Heart Condition

Chest Complaints

Asthma

Bone Disease

Epilepsy

Arthritis

HIV / AIDS

Reflux

Ulcer

Hernia

Diabetes

High Blood Pressure

Kidney Disease

Liver Disease

Bleeding Disorders

Blood Transfusions

Hepatitis

Radiotherapy

Drug Addiction

Depression

Anxiety

If you are female are you pregnant

Yes

Do you have any other medical conditions not already mentioned?

Are you taking any medications

In the last 5 years have you had any major operations?

Do you drink alcohol?

Yes

Amount per day

Do you smoke?

Yes

Amount per day

What is your approximate weight?

What is your height?

IMPORTANT: Authorisation to complete this form

Name of person completing this form *

First Name

Last Name

By checking this box you are indicating that you are authorised to complete this form. *

Patient

Parent / Guaridian

Date

YYYY

Thank you for registering as a new patient. We will be in contact with you shortly.

HOBART (Falconer House)
30 CASCADE ROAD,
SOUTH HOBART TAS 7004

LAUNCESTON
16 CANNING STREET,
LAUNCESTON TAS 7250

HOURS
Monday - Friday 8am - 5pm

Saturday & Sunday
EMERGENCIES ONLY

reception1@tomis.com.au
Call 03 6169 2129