Title*
First Name*
Middle Name (if applicable)
Surname*
Preferred Name*
Email*
Date of Birth (DD/MM/YYYY)*
Gender —Please choose an option—MaleFemaleOther
For “Other”, preferred pronouns
Mobile Phone*
Home Phone
Occupation
Residential Address (including suburb)*
Different address for Postal?* YesNo
Postal Address (including suburb)*
Medicare Number (10 digits)*
Ref*
Expiry (MM/YY)*
Name on card (if different to above)
Do you have Private Health Cover? YesNo
Private Health Fund* Name Member No* Number in front of your name* Type of Cover* —Please choose an option—Hospital CoverDental ExtrasHospital Cover & Dental ExtrasUnsure
DVA (Dept Vet Affairs) Number (if applicable)
Card Type
Expiry (MM/YY)
Is the patient 16 years or older? YesNo
NOTE: Compulsory for patients under 16 Name* Date of Birth (DD/MM/YYYY)* Phone Number* Address (including suburb)* Email* Medicare Number (10 digits)* Ref* Expiry (MM/YY)* Name on card (if different to above)
Name of emergency contact*
Relationship to patient*
Phone Number*
GP Name*
GP Phone*
Practice name and address*
Bleeding disorderAnticoagulationProsthetic heart valveHeart murmurPrevious heart surgeryPacemakerPrevious heart attackAnginaCongenital heart defect
Blood pressure: HighBlood pressure: LowAsthmaCOPDDiabetes: Type 1Diabetes: Type 2Liver diseaseCirrhosisHepatitis
Kidney diseaseNeurological disorderEpilepsyStrokeTIAAnxiety disorderDepressionThyroid disorderJoint replacement
OsteoporosisSteroid therapyCancerRadiotherapyChemotherapyGastro-oesophageal reflux
Any other conditions
Allergies
If smoking, how much?
If recreational drugs, what kind?
Current Medications
The above information is true to the best of my knowledge. I understand that I am financially responsible for any accounts. I authorise Hornsby Oral & Maxillofacial Surgery to access my health details on My Health Record and release any information required for my treatment or to process any claims. I authorise Hornsby Oral and Maxillofacial Surgery to contact me via SMS and email
Title* First Name* Middle Name (if applicable) Surname*
Date of Birth (DD/MM/YYYY)* Gender —Please choose an option—MaleFemaleOther For “Other”, preferred pronouns
Mobile Phone* Home Phone Occupation
Medicare Number (10 digits)* Ref* Expiry (MM/YY)*
DVA (Dept Vet Affairs) Number (if applicable) Card Type Expiry (MM/YY)
Name of emergency contact* Relationship to patient* Phone Number*
GP Name* GP Phone*
Bleeding disorderAnticoagulationProsthetic heart valveHeart murmurPrevious heart surgeryPacemakerPrevious heart attackAnginaCongenital heart defect Blood pressure: HighBlood pressure: LowAsthmaCOPDDiabetes: Type 1Diabetes: Type 2Liver diseaseCirrhosisHepatitis Kidney diseaseNeurological disorderEpilepsyStrokeTIAAnxiety disorderDepressionThyroid disorderJoint replacement OsteoporosisSteroid therapyCancerRadiotherapyChemotherapyGastro-oesophageal reflux
