Oral Surgery Patient Registration Form

PATIENT DETAILS

First Name *

Last 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 *

MaleFemale

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:

What surgery is offered
Potential benefits of the oral surgery procedure
Potential risks of the oral surgery procedure
Information about happy gas sedation which is offered complimentary with the surgery to ensure that you are comfortable and relaxed throughout the procedure
What’s involved in the recovery process after surgery
The likely amount of time off work required to recover from surgery (if applicable)
Quote for the surgical procedure
Potential dates for surgery to be held at your local dental practice
Answers to any questions you may have in regards to the surgery

Dental History

How anxious do you get when seeing the dentist? *

NoneMinimalSignificantExtreme

How anxious do you get when seeing the dentist?

NoneMinimalSignificantExtreme

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

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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