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03-351 9082
My practice:
Procedures
Patient Information
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Book An Appointment
03-351 9082
Procedures
Patient Information
About Us
Contact Us
Book An Appointment
Patient Information
Patient Online Registration
RJ Begg and Associates Oral and Maxillofacial Surgery
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Patient Information
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Patient Online Registration
Register
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First Name
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Title
*
Mr
Mrs
Miss
Ms
Last Name
*
Gender
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Male
Female
Residential Address
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Postcode
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Email Address
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Contact Number
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Emergency Contact Name
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Relationship to Patient
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Emergency Contact Address
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Emergency Contact Number
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Do you have medical insurance?
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Yes
No
If yes, please specify insurance company & policy number
Are you receiving any medical treatment at the present time?
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Yes
No
Have you ever been in hospital?
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Yes
No
Have you ever had?
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Rheumatic Fever
Epilepsy
Heart Trouble
Anaemia High
Blood Pressure
Asthma
Kidney Problems
Arthritis
Gastric Problems
Bronchitis / Chest Problems
Cold Sores
Severe Headaches
Depressive Illness
Are you taking any tablets, capsules, medicine or drugs?
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Yes
No
If yes, please specify all medication
Have you had any allergies to medicines that you are aware of?
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Yes
No
Are you wearing an artificial or prosthetic joint?
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Yes
No
Have you ever experienced excessive bleeding or bruising from dental treatment, cut or scratches?
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Yes
No
Have you ever had contact with the AIDS or Hepatitis B virus?
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Yes
No
Have you ever had a reaction to an anaesthetic?
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Yes
No
(Woman) Are you pregnant?
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Yes
No
If yes, please specify how many months?
Are there any other aspects concerning your health we should know about?
To my knowledge the above is a true and accurate account of my medical history and personal details.
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I undertake to pay any charges that I incur. If I have claimed to have my treatment covered by a third party, eg. ACC or Medical Insurance and the claim is not accepted within 3 months I understand that I am liable for the full cost of treatment received. In the event of non-payment of my account I will be liable for any recovery costs, legal fees and commissions that may be incurred in obtaining payment of my account. Additional costs to those estimated may be applicable eg. For additional follow up, urgent or emergency care or additional investigations.
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I consent to my personal details and clinical notes to be communicated to my referrer via email (unsecured) and where applicable, to other health care providers or third party (eg. GP, ACC, insurance provider) as part of my ongoing health care.
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