Patient Registration Form

To make your visit more smooth and efficient, please fill the below online form before coming to us.

Your Details
Name *
Name
Date of Birth *
Date of Birth
How did you hear about us? *
Emergency Contact Details
Emergency Contact Name *
Emergency Contact Name
Medical Details
At the present time are you taking any medication or tablets/or have you taken any medication or tablets during the last 6 months? *
Are you taking any Vitamins, herbal supplements or homeopathic medication *
Have you been under the care of a doctor: or in hospital during the past six months? *
Have you experienced any allergic/unusual effects from any tablets, drugs, injections or anesthetic *
Please tick you ever have had any of the following:
Do you have a bleeding problem, such as prolonged bleeding after surgery, anemia, or bruising? *
Have you had any prosthetic surgery? (e.g heart value or joint replacement) *
Are you taking any medications for Osteoporosis e.g. Fosamax, or an Aclasta Infusion *
Are you HIV positive? *
Are you hepatitis "A" "B" "C" positive? *
Do you smoke? *
Females: Are/could you be pregnant?
Insurance Details
Do you have any individual requirements? If yes, please provide more details.
Language *
Disability *
Religious, spiritual, cultural or family / whanau *
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 *
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 *
Health information: It may be necessary to release health information to your insurance provider / funder to obtain prior approval. *