Request an appointment

Title

First Name *

Last Name *

Patient Address *

Street address *

City *

State *

Postcode *

Contact numbers: Home

Work

Mobile *

Email Address

DOB *

Age

Occupation

Medicare Card Number *

Expiry date

Patient number on Medicare Card *

DVA card number (If applicable)

Do you have private health insurance? *

Yes No

Emergency contact/ Next of kin

First and Last Name

Relationship

Address

Street address

City

State

Postcode

Contact number: Home

Contact Number : Work

Contact Mobile

Person responsible for fees (If not the patient or in case of a minor)

Name

Relationship with patient

Person's Address

Street address

City

State

Postcode

Contact Number

Mobile Number

Date Of Birth

Medicare Card Number

48 hours prior to your appointment time you will receive a confirmation text, are you happy to receive this service?

YesNo

How did you hear about the practice?

Have you visited our website?

YesNo

Privacy Statement / Consent for I-Scribe

All staff at Eastside Oral & Maxillofacial Surgery respect the privacy of confidential information and seek to safeguard this information appropriately.

Details of our privacy statement can be obtained on request.

Our staff will take all possible steps to regulate and protect the collection, use, security and disclosure of personal and sensitive information.

We may use a note-taking program 'I-Scribe', to assist in the record-keeping of your consultation. It is aimed at providing accurate patient notes and correspondence.

Do you consent for the use of I-Scribe during your consultation? *

YesNo

Medical History

Who is your usual medical doctor/GP ? Name of GP clinic?

GP clinic address

Street address

City

State

Postcode

Have you had any serious illnesses, operations or hospitalizations in the past? If so please state

Have you ever taken or are you currently taking anticoagulants - Iscover, Plavix, Warfarin, Asprin, Xarelto or Eliquis? *

YesNo

Have you ever had a problem with excessive bleeding or bruising following a tooth extraction? *

YesNo

Have you ever taken or are you currently taking steroids - cortisone, prednisolone or hydrocortisone? *

YesNo

Have you ever taken medication for osteoporosis, hypercalcaemia, Paget’s disease or other bone or calcium problems in the past 10 years? *

YesNo

Have you ever had heart surgery, valve replacement, hip or joint replacement or have a pacemaker? *

YesNo

Do you smoke or vape? *

Yes No

How much do you smoke/vape per day?

Do you consume alcohol regularly? *

Yes No

How many units of alcohol do you consume per week?

Do you have any allergies? *

Yes No

What are you allergic to?

Have you or a family member ever experienced a bad reaction to general anaesthesia? *

Yes No

List your previous surgeries (If applicable)

Please list your medications

Are you pregnant?

YesNo

Are you breastfeeding?

YesNo

Signature of patient *

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Date *