Patient Registration Form

Child Benefits Schedule Bulk Billing Patient Consent Form

Download here

First Name

Last Name

Title

Gender

Male

Female

Phone

Address

Address Line

City

State

Post Code

Date of Birth

Text Input

Parent Details

This section for parent's of children only

Parent 1 First Name

Parent 1 Last Name

Parent 2 First Name

Parent 2 Last Name

Kindergarten

Suburb Kindergarten

End children's section

Aboriginal & Torres Strait Islander

Aboriginal

Torres Strait Islander:

Both

Medicare Card No.

Medicare Card Reference Number

Medicare Expiry Date

DVA Card Number

DVA Expiry Date

Private Health Fund

Yes

Name of Private Health Fund

Member Number:

Contact First Name

Contact Last Name

Emergency Contact Phone

Would you like to receive a reminder for your appointment?

SMS

Is this consultation related to Workcover or Work-related Injury?

Yes

Please read carefully and answer the following questions about your health and tick the relevant answer. Do you currently have or have you ever had any of the following:

Surgical operation under General Anaesthesia?

Yes

Reaction to General Anaesthesia?

Yes

Arthritis

Yes

Back or Neck Problems?

Yes

Diabetes

Yes Controlled by: Diet

Heart Condition or Surgery?

Yes

Pacemaker?

Yes

High Blood Pressure

Yes

Hepatitis B

Yes

Hepatitis C

Yes

Kidney Disease?

Yes

Osteoporosis?

Yes

Osteoporosis On Medication

Yes

When did you stop this medication?

Are you pregnant?

Yes

N/A

Do you smoke?

Yes

How many cigarettes a day?

llicit Drugs?

Yes

Are you on Methadone Program?

Yes

Do you have any allergies?

Yes

Allergies

Antibiotics

Other Medications

Food

Substance

Have you ever had any complications after dental treatment?

Yes

Any dental fear or phobia?

Yes

Anxiety/Depression?

Medicated

Non Medicated

Asthma

Mild

Moderate

Severe

Other Respiratory Disease?

Yes

Cancer

Yes

Heartburn, Acid Reflux or other Digestive System Problem?

Yes

HIV/AIDS

Yes

Infectious Disease?

Yes

Nervous System Condition?

Yes

Sensory Problems?

Yes

Thyroid Disease?

Yes

Autism?

Yes

ADHD?

Yes

Learning Delay?

Yes

Speech Delay?

Yes

Stroke?

Yes

Alcohol?

Yes, not heavy

Yes, heavy

Are you on any other regular medications?

Yes

Allergies

Blood thinners

Bisphosphonate

Steroids

Immunosuppressive

Cholesterol

List including over the counter:

Any other conditions?

Yes

Consent

I give consent for medical information to be obtained by my dentist for the purpose of my dental treatment and passed on to a third party for further treatment if required.

Yes

I give consent to release my results to my designated relative/carer.

Yes

Designated Relative/Carer

Designate Person's Phone

I give consent for my contact details to be obtained for the purpose of contacting me regarding medical matters or appointments.

Yes

Medical practitioners at Diggers Rest Medical Centre are committed to providing our patients with the best care. To do this it is essential that your health records are kept up to date and accurate. We recognise the importance of privacy and confidentiality for all our patients. Acknowledgement:

I acknowledge that all the information provided in this form is true and correct.

Yes

I agree to be responsible for all payments and will pay the amount due at their due time. I have read Payment Policy below.

Yes

Today's Date

Person responsible for the fees

Fee Payer's First Name

Fee Payer's Last Name

Fee Payer's Phone

Address

Address Line

City

State

Post Code

Payment Policy:

Our practice policy is to provide our valued patients with an estimate of their dental treatment cost before commencement. This may be completed verbally by our friendly dentists or nurses, and recorded in our notes, especially if urgent treatment is being performed.

As we are a private practice, payment for our dental service must be paid on the same day, otherwise will incur a fee of $75 for patients who do not meet these requirements.

We offer patients a range of payment options including:

Medicare (for eligible patients only)
Private Health Funds
DVA
Afterpay
ZIP

A non-refundable deposit may be required prior to major dental treatments.

Forms

Child Benefits Schedule Bulk Billing Patient Consent Form