Patient Registration Form

Name*

Date of Birth*

—Please choose an option—Day12345678910111213141516171819202122232425262728293031

—Please choose an option—MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

—Please choose an option—Year190019011902190319041905190619071908190919101911191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025

Sex*—Please choose an option—MaleFemaleNot Specified

Height*

Weight*

Mobile Number*

Email*

Address*

Do you have medical or dental insurance?*YesNo

Insurance provider

Plan

Membership number

Have you had your insurance for 12 months or more?YesNoN/A

Occupation

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact Phone Number*

Who is your GP?

NHI Number

At the present time are you taking any medication or tablets/or have you taken any medication or tablets during the last 6 months?*YesNo

If you have answered yes please provide more details

Are you taking any Vitamins, herbal supplements or homeopathic medication?*YesNo

If you have answered yes please provide more details

Have you been under the care of a doctor: or in hospital during the past six months*YesNo

If you have answered yes please provide more details

Have you experienced any allergic/unusual effects from any tablets, drugs, injections or anaesthetic?*YesNo

If you have answered yes please provide more details

Please tick if you have had any of the followingHeart TroubleHeart MurmurArthritisAsthmaRheumatic feverJaundice or HepatitisAnemiaEpilepsyDiabetesBruise EasilyKidney problemsLow Blood PressureHigh Blood Pressure

Any other medical conditions? Please provide more detail

Do you have a bleeding problem, such as prolonged bleeding after surgery, anemia, or bruising?*YesNo

Have you had any prosthetic surgery? (e.g heart value or joint replacement)*YesNo

Are you taking any medications for Osteoporosis e.g. Fosamax, or an Aclasta Infusion?*YesNo

Are you HIV positive?*YesNo

Are you hepatitis "A" "B" "C" positive?*YesNo

Do you smoke?*YesNo

Are/could you be pregnant?*YesNo

Have you or any of your family or friends have travelled overseas recently?*YesNo

If yes, to which country have you / they travelled?

Language*YesNo

Disability*YesNo

Religious, spiritual, cultural or family / Whanau*YesNo

Do you want your Extracted Teeth returned. Body parts: if your procedure requires the removal of a body part would you like it returned if this is possible?*YesNo

Is there anything else we need to know to help us plan your care? Please detail below. You will have the opportunity to discuss this with your nurse / surgeon prior to your surgery?*YesNo

If you have answered yes please provide more details

How did you hear about us?*Referred by DentistReferred by GPReferred by InternetReferred by RadioReferred by Newspaper MagazineReferred by Yellow PageReferred by FriendsReferred by Other

Please review and confirm your answers.
We require 48 hours' notice for all cancellations or 30% of that appointment will be charged.
For insurance purposes, it may be necessary to release health information to your insurance provider to obtain your prior approval.
I acknowledge that my health information may need to be released to the insurance provider and give my informed consent for this to occur.I Accept