Patient Registration & Privacy Form

Personal Information:

* indicates required field

Title:

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?

Person responsible for payment: (if not you please fill section below)

Name:

Surname:

Date of birth:

Phone Home:

Work:

Mobile:

address:

Postcode:

Medical Information:

Physician's Name:

Telephone:

(women) Are you Pregnant?

Have you had any previous illnesses? (if yes please state below)

Have you ever been advised to take antibiotics before dental treatment?

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?

Dental Information:

Reason for today's visit?

Former Dentist:

Approximate date of last dental visit:

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:*

Initials*