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. *