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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
Do you have a DVA gold card? *
Do you have private health insurance? *
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
Are you taking any medications? (including over the counter pills & tablets) *
Are you allergic to any medications? *
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? *
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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