Patient's DetailsPatient's NameDate of BirthEmail AddressMedical HistoryYour answers will help our surgeons provide you with the most appropriate treatmentThe information you give is strictly confidentialYour honesty may assist in avoiding health problems1. Have you ever suffered from any of the following? UnsureNoYes If yes, please tick where appropriate Heart diseaseHigh blood pressureRheumatic feverAsthmaDiabetesKidney diseaseHepatitisEpilepsyAnaemiaOsteoporosisOther prolonged illness, please give details2. Do you have any allergies to any medications or substances?UnsureNoYes If yes, please tick where appropriate PenicillinPain killersIodineAnti-inflammatoriesCodeineLatexOther medication/drug/substance, please give details Reactions: RashSwellingVomitingOther, give details 3. Have you had any operations?UnsureNoYes4. Have you or your family had any problems with general anaesthesia?UnsureNoYes5. Have you ever had prolonged bleeding following tooth extraction, cut or injury?UnsureNoYes6. Are you currently under any long term medical treatment?UnsureNoYes7. Do you take any of the following Medications?UnsureNoYes If yes, please tick where appropriate WarfarinAspirinPlavixAny other blood thinning medication8. Are you taking any medications or drugs regularly?UnsureNoYes 9. Do you use recreational drugs? (E.g. cannabis, cocaine, heroin)UnsureNoYes10. Do you consume alcohol?UnsureNoYesIf yes, how many glasses per day?0-55-1010 or more11. Do you smoke?UnsureNoYesHow many per day?< 1020-3030-6060+12. If female, might you be pregnant?UnsureNoYes13. Are there any other health issues you wish to discuss with your surgeon?UnsureNoYes14. Is there anything your surgeon should be aware of that is not on this form?UnsureNoYesAddition InformationAdditional Information RequiredIs the patient a minor? (Aged 16 or under)NoYesParents DetailsAccounts for patient will be issued under parents name.Parent's nameParent's Date of Birth Parent's Medicare DetailsReference Number012345678910Patient's Medicare DetailsReference Number012345678910 Private Health Fund DetailsReference Number012345678910Primary ContributorHealth Fund coverHospitalDental/ExtrasConcession CardNext of Kin DetailsGeneral Dentist DetailsGeneral practitioner (GP) DetailsReferrering DoctorDentist (as above)GP (above)Other (please enter details below)Referring doctorYour Referral If you have a copy of your referral please upload hereX-ray Imaging If you have a copy of your x-ray imaging please upload hereI have read and accepted the privacy policyAgree Δ
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