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Refer Patients Online
Title
First name *
Last name *
Middle name
Preferred name (What do you like to be called?)
Gender
Male
Female
Date of birth *
Phone *
Email
Address *
Do you have a medicare card? *
Yes
No
Medicare card number:
Do you have a DVA gold card? *
DVA gold card number:
Do you have private health insurance? *
Card number:
Occupation:
Indigenous status:
Aboriginal
Torres Strait Islander
Neither
Dental practitioner
Dental practitioner's address
Medical practitioner
Medical practitioner's address
Emergency contact first name *
Emergency contact last name *
Emergency contact phone *
Relationship to emergency contact *
Do you currently have, or have you ever had any of the following? *
Alcohol abuse
Asthma
Cancer
Diabetes, Type 1
Diabetes, Type 2
Epilepsy
Stroke or TIA
HIV/AIDS
Migraine headaches
Mental illness
Arthritis
Bleeding disorders
Cold sores
Diabetes, Gestational
Hepatitis A, B or C
Kidney trouble
Tuberculosis
Osteoporosis
Anaemia
Bronchitis
Drug dependence
Heart trouble
High blood pressure
Rheumatic fever
Depression
Other bone disease
Gastric problems
Other respiratory or lung disease
Other
None/Not applicable
Details if selected 'Other':
Are you taking any medications? (including over the counter pills & tablets) *
Details:
Do you have any allergies?
Details of allergy
Have you had joint replacement surgery? *
Have you had any other surgery or any other anaesthetic? *
Have you ever seen any other specialists? *
Have you ever experienced excessive bleeding or bruising from cuts, scratches or surgery? *
Have you or any member of your family ever had a reaction to an anaesthetic? *
Can you easily walk up two flights of stairs without stopping? *
Do you smoke? *
Do you drink alcohol? *
Do you have any loose teeth, veneers, crowns, caps, braces or dentures? *
Have you ever experienced any jaw joint (TMJ) symptoms such as clicking or popping noises, locking, pain or limited mouth opening? *
What is your weight? *
What is your height? *
Is there anything else regarding your health that you think we should know about?
How would you rate your overall comfort with dental treatment? *
Very uncomfortable/anxious
Somewhat uncomfortable
Neutral/unsure
Mostly comfortable
Very comfortable
How would you prefer your treatment to be performed (you can select more than one option)? *
Local anaesthetic (fully awake in dental chair)
Nitrous Oxide (happy gas) or Green Whistle
Intravenous sedation/twilight sleep (very drowsy & groggy in the dental chair)
General anaesthesia (fully unconscious in hospital)
No preference/Don't know/Whatever the surgeon thinks is best
Do you allow your treatment records to be utilised anonymously for teaching or education purposes? *
Are there any other details you wish to disclose?
The medical history I have given is true and correct to the best of my knowledge
I have disclosed all medications including over-the-counter and herbal remedies that I am taking
I give permission for a copy of this online form to be sent via email to The Oral Surgery Specialist Clinic
I give permission for a copy of correspondence letters and test results to be sent to the clinicians I have indicated on this form
Submit
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