Shop 1-1060 Thompson Gateway
Corner of Thompsons and Evans Road
Cranbourne, VIC 3977
03 5995 9789
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Dr. Rose Mathew
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General Dentistry
Examination
Extraction
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Mouthguards
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Root Canal Treatment
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Patient Registration & Privacy Form
Patient Registration & Privacy Form
Personal Information:
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indicates required field
Title:
Mr
Mrs
Miss
Ms
Dr
Name:
Surname:
Date of Birth:
Street address:
Postcode:
Email:
Telephone Home:
Mobile:
Telephone Business:
Postal Address (If different from above):
Emergency contact name, number and relationship.
Medicare number & Ref:
Exp:
Name:
Health insurance card number:
reference no:
Exp:
How did you hear about Shine dental Group?
website
advertising
personal recommendation
health engine
others
Person responsible for payment: (if not you please fill section below)
Myself
Other
Name:
Surname:
Date of birth:
Phone Home:
Work:
Mobile:
address:
Postcode:
Medical Information:
Physician's Name:
Telephone:
(women) Are you Pregnant?
No
Yes
Have you had any of the following?:
Arthritis/Rheumatism
Artificial Joints (knee, hip etc.)
Asthma
Blood pressure High or low
Cancer, Tumour or other malignancy
Chest pain
Congenital Heart disease
CJD: High / low Risk
Heart alignment (heart attack, coronary artery disease, cardiac surgery)
Heart Murmur
Hepatitis or Liver disease
HIV / AIDS
Kidney Disease
Osteoporosis or any other bone disorder
Radiation or chemotherapy
Diabetes
Disability (physical or developmental)
Emphysema or other lung disease
Epilepsy
Excessive bleeding or blood disorder
Rheumatic fever
Special Needs (Autism, Developmental Delay etc.)
Stroke or other CVA
Teberculosis
Have you had any previous illnesses? (if yes please state below)
Have you ever been advised to take antibiotics before dental treatment?
No
Yes
Do you have any allergies/allergic to any medication?
List medications you are currently taking:(also in particular medications for osteoporosis, blood thinners eg warfarin which can affect the dental treatment provided )
Have you ever had any compilations following dental treatment?
No
Yes
Dental Information:
Reason for today's visit?
Former Dentist:
Approximate date of last dental visit:
Please tick if the following apply to you:
Bad breath
Broken fillings
Blister on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cosmetic improvement/Makeover
Dry Mouth
Food collection between the teeth
Clench or grind teeth
Growths or sore spots in your mouth
Gums swollen, tender or bleeding
Jaw pain or tiredness
Lip or Cheek biting
Loose tooth
Orthodontics (Braces)
Sensitivity to pressure or irritants (cold, hots or sweets)
Tooth replacement options (dentures, crowns, bridges, implants)
Wisdom teeth problems
Other
Privacy Agreement & Patient Consent:
I understand the shine dental group and associated Medical & Dental clinics comply with the privacy act (1988) and as part of their privacy are committed to protecting the privacy of individuals and their personal information. by ticking and submitting below indicates that i have read the above and consent to Shine Dental Group collecting, using, storing and disposing of my personal information; the release of relevant personal information to other health professionals to allow quality dental care; inclusion in a recall register to be advices of the following up visits. I understand I may withdraw my consent for Shine Dental group to us and disclose my personal information (except when legal obligations must be met).
I Agree:
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Initials
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