Oral Surgery Patient Registration Form

PATIENT DETAILS

First Name *

Last Name *

Preferred Name *

Date of Birth *

Mobile *

Home Phone

Patient Address *

Email *

Medicare Card Number and Reference *

Name of your regular dental practice *

Do you have private Dental insurance *

YesNo

Provider *

Reason for referral

Social History

Age *

Ethnicity *

Gender *

MaleFemaleOther

Occupation *

Appointment availability

The consultation appointment is typically conducted by videoconsultation (Google Meet) for 15minutes and attracts a fee of $90.

In the consultation the following will be discussed:

The surgical options including no treatment, monitoring of their condition, the surgical alternatives and specialist referral

The sedation options including no sedation (local anaesthesia only), oral sedation, happy gas sedation, IV sedation and specialist referral for general anaesthesia

Potential benefits & risks of the above

What’s involved during the surgery

What to expect during recovery including estimated time off work

Potential available dates for your procedure

Answers to any of the patient’s questions including Dr. Daniel’s direct email and mobile number to be contacted by the patient, should the patient subsequently have any additional questions after the consultation appointment.

Quote (valid for 3months only)

Dental History

Dental visits *

3monthly6monthlyYearly Only when I have too

How often, on average, do you see your dentist?

3monthly6monthlyYearly Only when I have too

Medical History

Please document any other known medical conditions here or ‘N/A’ if not applicable: *

Please document any prior surgery procedures here or 'N/A' if not applicable *

Medication History

Please document any other known medications here, including prescription, over the counter, herbal remedies or n/a if not applicable *

Please document any known drug allergies *

Medical assessment for Sedation

IV Sedation (Sleep Dentistry) *

YesNo

Have you had IV sedation (Sleep Dentistry before)

YesNo

If yes, how was your experience for IV sedation? Otherwise write N/A *

EMERGENCY CONTACT DETAILS

Name *

Relationship to you *

Mobile Phone *

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

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