New Patient Registration - TASMANIAN ORAL, MAXILLOFACIAL AND IMPLANT SURGERY (TOMIS)

PATIENT REGISTRATION

This form is for new patients to complete.

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. If you have any concerns, please ask to speak to the Practice Manager.

Name(Required)

Title First Last

Date of birth(Required)

Email(Required)

Phone Number(Required)

Address(Required)

Street Address Address Line 2 City State Post Code Country

Country of Birth

Preferred Language

Occupation

General Practitioner(Required)

First Name Last Name

Name of Practice

Is your GP your referring Doctor?

Yes

Referring Doctor

First Name Last Name

Name of Practice

General Dentist's Name

First Name Last Name

Name of Dental Practice

Do you have a Medicare Card?(Required)

Yes

Medicare Number (Required)

Ref. Number (Required)

Expiry Month

Expiry Year

Do you have private health insurance?(Required)

Yes

Private Health Fund Name

Member Number (Required)

Month Joined

Year Joined

Hospital Cover over 12 months

Yes

Level of Cover

Gold

Silver

Bronze

Do you have overseas health insurance?(Required)

Yes

Overseas Fund Name

Member Number (Required)

Month Joined

Year Joined

Pension or Health Care number

Expiry Month

Expiry Year

Are you covered by Department of Veterans Affairs?(Required)

Yes

DVA Number (Required)

Card (Required)

Expiry Date

Workers Compensation Claim(Required)

Yes – please contact the Practice.

Do you have any allergies?(Required)

Yes – IMPORTANT – list all allergies below

Allergies to Medications

Or any bad reactions to Endone, Morphine, Latex tapes for example.

Do you take any blood thiners?

Yes – Please list

Blood Thinners (Pradaxa, Xarelto, Warfarin, Heparin, Other…)

Are you Diabetic

Yes

Current Diabetes Treatment

Diet

Tablets

Insulin

Please list your diabetic medications below

Medical History & Current Conditions

Rheumatic Fever

Yes

Heart Condition

Yes

Chest Complaints

Yes

Asthma

Yes

Bone Disease

Yes

Epilepsy

Yes

Arthritis

Yes

HIV / AIDS

Yes

Reflux

Yes

Ulcer

Yes

Hernia

Yes

Diabetes

Yes

High Blood Pressure

Yes

Kidney Disease

Yes

Liver Disease

Yes

Bleeding Disorders

Yes

Blood Transfusions

Yes

Hepatitis

Yes

Radiotherapy

Yes

Drug Addiction

Yes

Depression

Yes

Anxiety

Yes

If you are female could you be pregnant?

Yes

COVID 19 Vaccinated

Yes

Do you have any other medical conditions not already mentioned?

Please list.

Are you currently taking ANY medications?(Required)

Yes – list all medications below

Are you taking any medications (tablets, mixtures, injections, puffers etc.) Please list.

In the past 5 years have you had any major operations?(Required)

Yes – list ALL major surgeries

List ALL major operations in the past 5 years.

Do you drink alcohol?

Yes

Amount per week

Do you smoke?

Yes

Amount per day

What is your approximate weight?

What is your approximate height?

Emergency Contact Information

Emergency Contact Person(Required)

First Last Relationship

Emergency Person Contact Phone Number(Required)

Authorisation

IMPORTANT, by clicking the submit button below you are indicating that you are the Patient or Parent / Guardian of the Patient and legally authorised to complete this form and agree to our terms and conditions below in relation to how this information may be used.

Name of person completing this form?(Required)

Comments

This field is for validation purposes and should be left unchanged.