02 9601 5111
02 9601 5111

online registration

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Personal & Contact Details

This website is protected using an SSL certificate which provides security and secures your data while it is being transferred. Please carefully complete the questionnaire below. The information collected is essential to provide you with the best professional care. Thank you for your cooperation.
Date of Birth
Email

Address

Address

Health Funds & Insurance

A. Do you have a medicare card?
B. Do you have a DVA Gold card?
C. Do you have private health insurance?

General

Indigenous status

Health Team Members

Click or drag files to this area to upload. You can upload up to 5 files.
Please take a photo of your referral letter and upload, in addition to any relevant xrays and photos.

Emergency Contact

Emergency contact name

Health Questionnaire

1. Are you currently receiving medical treatment?
2. Have you ever been admitted to hospital?
3. Do you or have you ever had any of the following?
4. Are you taking any medications?
Including over the counter pills & tablets.
5. Are you allergic to any medication?
6. Have you had joint replacement surgery?
e.g. prosthetic knee, hip
7. Have you had any other surgery or any other anaesthetic?
8. Have you ever seen any other specialists?
9. Have you ever experienced excessive bleeding or bruising from cuts, scratches or surgery?
10. Have you ever had contact with the hepatitis or AIDS/HIV virus?
11. Have you or any member of your family, ever had a reaction to an anaesthetic?
13. Can you easily walk up two flights of stairs without stopping?
14. Do you smoke?
15. Do you drink alcohol?
16. Any family history of cancer?
17. Have you had COVID in the last 30 days?
18. Do you have any loose teeth, veneers, crowns, caps, braces or dentures?
19. Have you ever experienced any jaw joint (TMJ) symptoms such as clicking or poping noises, locking, pain, or limited mouth opening?
This may be needed to calculate the correct dose of certain medications and anaesthetic drugs.
This may be needed to calculate the correct dose of certain medications and anaesthetic drugs.

Other Information

Selected Value: 5
Please drag to indicate (0 = extremely comfortable, 10 = extremely distressed)
H. How would you prefer your treatment to be performed (you can select more than one option)?

Declaration & Signature

Declaration