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Precision Surgery, Personalised Care.
02 9262 9318
Suite 6, 281-287 Sussex St, Sydney NSW 2000
Home
About Us
Scope of Practice
Extractions
Wisdom Teeth
Dental Implants
Grafting
Orthognathic Surgery
Dentoalveolar Surgery
Oral Medicine & Pathology
Facial Trauma Treatment
Appointments
Patient Information
Post-Operative Information
Preparation for Hospital Admission
New Patient Form
Meet the team
Locations
Contact Us
Home
About Us
Scope of Practice
Extractions
Wisdom Teeth
Dental Implants
Grafting
Orthognathic Surgery
Dentoalveolar Surgery
Oral Medicine & Pathology
Facial Trauma Treatment
Appointments
Patient Information
Post-Operative Information
Preparation for Hospital Admission
New Patient Form
Meet the team
Locations
Contact Us
Make a Referral
Patient Registration Form
Please complete this registration form before your appointment. Your details help us prepare for your visit and keep your records up to date. All information is kept confidential.
Patient Registration Form
"
*
" indicates required fields
Patient Details
Title
Name
*
First
Last
Preferred Name
*
Date of Birth
*
Patient Email
*
Phone
*
Address
*
Do you identify as Aboriginal or Torres Strait Islander?
*
Yes
No
Language / Ethnicity:
Medicare and Private Health Insurance Details:
Medicare Card Number
Ref No
Expiry
What does your insurance cover?
Covers medical expenses only
Covers dental expenses only
Full cover
Health Fund Name
Health Fund Number
Do you have a Department of Veteran’s Affair Card?
*
Yes
No
Type
*
Number
*
Expiry
*
Colour
*
Person responsible for account (compulsory for patients under 18 years)
Title
Name
First
Last
D.O.B.
Email
Medicare Card Number
Ref No
Expiry
General Dental and Medical Practitioner:
Dental Practitioner:
Dental Practitioner Location:
Medical Practitioner:
Medical Practitioner Location:
Other Treating Specialists:
Emergency Contact / Next of Kin / Substitute Decision Maker:
Next of Kin Title
Next of Kin Name
*
First Name
First Name
Preferred Name
Next of Kin D.O.B.
Next of Kin Email
Next of Kin Phone
Do you have an advanced health care directive?
*
Yes
No
Medical History
No Medical Issues
No Medical Issues
Cardiovascular
Heart Disease
High blood pressure
Stroke / TIA
Rheumatic Fever
Pacemaker / artificial valve
High Cholesterol
Respiratory
Asthma
Other breathing problems
Haematological
Bleeding or Clotting disorder
Anaemia
Neurological
Epilepsy / seizures
Autism
Oncology
Cancer (Type)
Previous radiotherapy
Oncology - Cancer
*
Please specify
Endocrine / Metabolic
Diabetes
Osteporosis
Weight loss medications eg. Ozempic / Mounjaro / Wegovy
Immune / Infections
Immune Systems Issues
MRSA
RSV
Other Known Infectious Conditions
Other Known Infectious Conditions
*
Please specify
Gastrointestinal / Liver / Kidney
Kidney Disease
Liver Disease
Hepatitis A
Hepatitis B
Hepatitis C
Musculoskeletal
Artificial Joines (Hip, Knee etc)
Social History / Lifestyle
Smoking
Vape
Recreational drug use
Mental Health
Depression / Anxiety
Falls Risk
History of falls in last 6- 12months
Mobility Issues / require assistance
Walking aid use
Skin Integrity
Skin Intact
Fragile Skin
Wound / Ulcers
Pressure Injury Risk
Family Planning
Are you pregnant or is there a possibility you maybe pregnant?
*
No
Unsure
N/A
Yes
When is your due date?
Allergies
Medications
Consent
Do you consent to receive SMS and Emails for reminders for appointments?
Yes
No
Acknowledgement
*
The above information is true to the best of my knowledge
*
Patient / Parent / Guardian Signature
*
Contact Details
02 9262 9318
admin@vintagesurgicalspecialists.com.au
Suite 6, 281-287 Sussex St, Sydney NSW 2000
