Jaw Surgery Brisbane

New Patient Information

Sex

Contact Details

Doctor Details

Medicare & Health Insurance Details:

Medicare Details:

Private Health Insurance

Dental Extras Fund:
Hospital Cover:

Veteran Affairs

VAC/Workcover

Medical Summary

Have you had or currently have:

Do you have any allergies to:

Do you smoke cigarettes / or use tobacco products?

Are there any other "risk factors" you need to discuss in your consultation?

Have you EVER taken any medications for osteoporosis or bone conditions / lesions? (eg' Fosamax' Actonel, Zometa, Pamisol, Didronel, Didrocal, orAredia)

Please list ALL medications you are currently taking (including vitamin supplements and inhalers):

Please list ALL previous operations:

Describe any serious illness You suffered:

Are you pregnant?
Are you taking the oral contraceptive pill?
Have you had problems with general anaesthetics or a family history of malignant hyperthermia?

PRIVACY STATEMENT:

Our practice respects your right to privacy and compries with the regisration relating to the collection, storage, use and disclosure of health information. For more information please ask for the 'Privacy Statement Handout'.

 

Level 5, Morris Towers
149 Wickham Terrace
Brisbane, QLD 4000

E reception@faciomax.com
F: 07 3107 1605