Patient's Details



Medical History

  • Your answers will help our surgeons provide you with the most appropriate treatment
  • The information you give is strictly confidential
  • Your honesty may assist in avoiding health problems


  • UnsureNoYes
    If yes, please tick where appropriate
    Heart diseaseHigh blood pressureRheumatic feverAsthmaDiabetesKidney diseaseHepatitisEpilepsyAnaemiaOsteoporosisOther prolonged illness, please give details

  • UnsureNoYes
    If yes, please tick where appropriate
    PenicillinPain killersIodineAnti-inflammatoriesCodeineLatexOther medication/drug/substance, please give details

    Reactions: RashSwellingVomitingOther, give details

  • UnsureNoYes


  • UnsureNoYes


  • UnsureNoYes

  • UnsureNoYes


  • UnsureNoYes
    If yes, please tick where appropriate WarfarinAspirinPlavixAny other blood thinning medication

  • UnsureNoYes

  • UnsureNoYes

  • UnsureNoYes
    0-55-1010 or more

  • UnsureNoYes
    < 1020-3030-6060+

  • UnsureNoYes

  • UnsureNoYes

  • UnsureNoYes

  • BroadmeadowForster, Maitland or Port Macquarie


  • Additional Information Required

  • NoYes


  • Parents Details

    Accounts for patient will be issued under parents name.






  • HospitalDental/Extras






  • Dentist (as above)GP (above)Other (please enter details below)

  • If you have a copy of your referral please upload here


  • If you have a copy of your x-ray imaging please upload here


  •