Adelaide Oral & Maxillofacial Centre
Dr Ramon Baba
Dr Jacques De Wet
Dr Tony Mavrokokki

Dear patient, You have been referred to AOMC.
Please complete this secure online patient form prior to your appointment, thank you.

Patient Information - Confidential

Demographics

Salutation

SURNAME *

FIRST NAME *

SECOND NAME

Gender

MF

DATE OF BIRTH (day) *

(month) *

(year) *

Phone (Home)

Phone (work)

Phone (Mobile)

Your Residential Address: *

Your confidential email address

Postal Address (if different to above)

Occupation

Religion

Next of Kin

Next of Kin phone

Relationship:

Alternative contact

Alternative contact phone

I am an Indigenous Australian

I am a Torres Strait Islander

Referral details

Referred by:

Your dental practitioner

Your medical practitioner (GP):

Contact phone:

Any other relevant specialist:

Contact number:

Health insurance details

Your medicare number:

Valid to:

Patient reference number

Are you a member of a private health fund?

NOYES

Do you have private hospital cover?

NOYES

Do you have extras (dental) cover?

NOYES

If yes, which fund?

Other fund (not listed)

If yes, Membership number

Are you a Veterans Affairs member?

NOYES

Veterans Affairs Card colour

Veterans Affairs card number

Patient medical history - confidential

Please answer the following by placing a tick in the appropriate box

2. Are there any other conditions or treatments you have not already disclosed above?

NOYES

What conditions?

Have you ever received medications, tablets, or injections for the treatment of osteoporosis, or low bone density?

NO YES

If yes, please list medications below

4. Do you closely associate with people in the high risk group for communicable diseases? E.g: Health care workers, Ambulance officer, Nurses, Doctors

NOYES

Please describe your association:

5. Have you taken any medications on a regular basis for the past year? This includes prescription and non-prescription (herbal) medications

NOYES

Please list your regular medications

6. Have you ever had an operation?

NOYES

What was the operation for?

-- If yes, were there any unusual reactions to the general anaesthetic?

NOYES

-- Has any one of your family ever had any unusual reaction to a general anaesthetic?

NOYES

Please specify the reaction:

7. Have you any allergies to drugs or medication?

NOYES

Please list allergies to medications

8. Females: are you on the pill?

NOYES

- Are you pregnant?

NOYES

If yes, how many weeks

9. Do you smoke?

NOYES

How many cigarettes a day?

10. Do you drink alcohol?

NOYES

- How many glasses per day?

- OR How many glasses a week?

11. Do you take any recreational drugs?

NOYES

What recreational drugs?

For hospital requirements please provide your esitmated:

height (cm)

Weight (kg)

Consent

In addition to my information being used for essential communication between my doctor and specialists as part of my treatment I consent for my xray/photographic images to be used for: Publishing on social media, educational and lecturing purposes (Your personal information with remain anonymous)

NOYES

Payment

I understand that I am responsible for the payment of my account.
I understand that the consultation fee must be paid on the day of attendance.
I understand that full payment is required one week prior to my surgery.
I consent for Adelaide Oral and Maxillofacial Centre to submit claims to Medicare on my behalf.
I understand if I default on payments after my treatment is completed that further action will be taken.

Person responsible for this account (enter full name) *

Have answered the above to the best of my ability

SIGNED *

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*If using a touch screen use your finger or stylus to sign, *If using a PC hold down left mouse button and drag to sign

DATE signed *