Patient ID form

CLIENT DETAILS

Please specify

Surname *

Given Names *

Date of Birth *

Gender *

MFOther

Please specify

Address *

Suburb *

Postcode *

Mobile Phone *

Work Phone

Home Phone

Email Address

GP (Medical)

Full Name

Phone

Clinic Name and Address

Department of Veterans Affairs File No

DVA card colour

GoldWhite

Do you have Private Health Insurance? *

YesNo

Private health insurance fund name *

Private health insurance membership number *

What is your level of cover? *

HOSPITAL ONLYEXTRAS ONLYHOSPITAL AND EXTRAS COMBINED

Next of Kin *

Phone *

Contact Address *

MEDICARE CLAIMING DETAILS

Medicare Card Number *

No. (IRN) *(next to name)

Expiry *

Is someone else paying for the account on behalf of the patient? *

YesNo

Please provide claimant details for Medicare rebate:

Claimant name

Claimant Date of Birth

Medicare Card Number

No(next to name)

Expiry

Address

MEDICAL HISTORY

Please list ALL current medications you are taking (If none please type nil) *

Do you have any allergies? *

YesNo

Please provide details of allergies *

Have you ever taken Bisphosphonates (eg:Prolia)? *

Yes No

Please provide details of bisphosphonate medication *

Do you take aspirin or blood thinner regularly? *

YesNo

Are you pregnant? *

YesNo

Are you a smoker? *

YesNo

Please provide details of ALL past and present medical conditions (If none please type nil) *

The information provided above is correct to the best of my knowledge. *

Signature *

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Date *

CONSENT TO COLLECT PATIENT’S INFORMATION

Recent changes to the Privacy Laws now mean that a person’s written consent is required for a health professional to obtain medical information concerning that person, and to communicate medical information about that person with another health practitioner.

In view of this, the following form will need to be signed if you are happy for Dr John Cosson to obtain such information and to liaise with other health practitioners concerning your condition.

I *

D.O.B. *

give permission for Dr John Cosson

To obtain medical information, details of previous consultation and results of investigations performed from other medical practitioners, hospitals and health care providers that pertain to my medical condition.
To communicate with the referring medical practitioner concerning my medical condition.
To communicate with other health professionals directly involved with my medical condition.

Please note: Any OPG’s (x-rays) or Scans which are left at the premises of Coastal Oral and Facial Surgery that have not been collected within 12mths will be disposed of.

Name (Parent/Guardian if Patient if under 18yrs)

Date

Signature *

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