Your Personal Details:

Gender:

MaleFemale

Title:

Date of Birth:

First Name:

Preferred Name:

Surname:

Postal Address:

Suburb:

Postcode:

Mobile #:

Home #:

Work #:

Email Address:

Occupation:

Nationality:

Would you like to be added to our mailing list: YesNo

Name of Health Fund:

Reference No.:

Best confirmation method for appointment (please check): SMSTelephoneEmail

Person to contact in case of emergency:

Relationship:

Phone Number:

Information about your Medical/Dental History:

GP Name:

Phone #:

Are you currently undergoing any medical treatment or had any surgery within the last 12 months? YesNo

Are taking any medication, drugs or pills now? YesNo

If yes, name medication and dosage:

Are you taking any Biphosphonate Medications?

Do you have any allergies?

Please indicate below if you have had, or have at present any of the following:

Are you pregnant? YesNo

Breast Feeding? YesNo

Crohn's Disease:

YesNo

Smoker:

YesNo

Have / Having Botox:

YesNo

Heart Disease/Attact/Surgery:

YesNo

Heart Pacemaker:

YesNo

Artificial Heart Valve:

YesNo

Sjrogren's Syndrome:

YesNo

Join Replacement (Hip, Knee, etc.):

YesNo

Join Replacement Date:

Bone Disease:

YesNo

Cance:

YesNo

Chemotheraphy/Radiation:

YesNo

Asthma:

YesNo

Fainting/Dizzy Spells:

YesNo

Epilepsy:

YesNo

Sinus/Hay Fever:

YesNo

Rheumatic Fever:

YesNo

Stomach Ulcers:

YesNo

Thyroid Problems:

YesNo

Diabetes:

YesNo

Stroke:

YesNo

Tuberculosis:

YesNo

Haemophilia:

YesNo

Emphysema/Chronic Cough:

YesNo

HIV / AIDS:

YesNo

Blood Pressure (High / Low):

YesNo

Latex Sensitivity:

YesNo

CJD:

YesNo

Osteoporosis:

YesNo

Arthritis:

YesNo

Rheumatoid:

YesNo

Hepatitis A/B/C:

YesNo

Other:

We request and expect payment at the time treatment. For your convenience we accept cash, cheques, eftpos, all major credit cards. Also note that you are responsible for any costs incurred by our practice for recovery of outstanding payments. I understand that payment of the account is my responsibility, and that my Health Fund (if any) will not cover the full amount. I understand to pay any expenses incurred or to be incurred in the collection of any overdue portion of this account.

Patient / Guardian Signature (Print Name):

Date: