Patient Registration

Patient Registration Form

Title

First Name

Last Name

Preferred Name

Gender

Date of Birth

Occupation

Address

Dental Cover

Phone/Mobile

Hospital Cover

Emergency Contact

Name

Relationship

Medical Practitioner

Phone

Dentist

Practice Name

Any other medical condition/s not listed above

Surgery or Hospitalisation in the last 12 months for any reasons

Please list the name of all the medical condition/s that you had or currently have and are not listed above:

Please list the name of all the medication/s including over the counter or others that you are taking:

Do you take or had Medications/Injections for bone issues such as PROLIA and or BISPHOSPHONATE?

Are you Currently Pregnant?

Pregnancy due date

Do you Smoke?

What do you smoke?

How many for day

Do you drink alcohol?

How many per week

Please specify your allergy and reaction

How did you hear about us?

I want to book an appointment for

Consult

Consult and procedure

Please select your follow-up appointment

In Person

Telehealth

Medical History
Please read carefully, tick Yes or No, and Box if you have or have had any of the following medical conditions.

Please select your follow-up appointment

I confirm that the above contains my complete medical history to the best of my knowledge. Any alteration will be reported at subsequent appointments.

I consent for a copy of this online form to be sent via email to admin SOSIS.

I consent to SOSIS communicating with my healthcare providers for the purpose of collecting and storing my medical and dental records.

I understand the privacy statement and consent to sharing my medical and dental records with my referring clinicians and other healthcare providers.

I confirm that I am financially responsible for all accounts.

I consent to the taking of clinical photographs and their use, with my identity reasonably protected, for education and training purposes.

Patient or Guardian Signature

We may collect your personal information required for your management. We understand that your personal information and health record is confidential. Your records will only be shared with health practitioners if consented. Our policy is to maintain the security of your personal and health information which is only accessible by authorised staff members for the purpose of your treatment only.

Please select your follow-up appointment

In Person

Telehealth

Patient/Guardian Name

Patient/Guardian Signature

Date / Time

Get In Touch

Locations

Emergency Contact