New Patient Form

Gender: —Please choose an option—MALEFEMALE

Title: —Please choose an option—MrMrsMissMsDrProf

First Name:

Surname:

Date of Birth:

Address:

Postcode:

Home Phone:

Work Phone:

Mobile Phone:

Email Address:

Occupation:

Whom may we thank for referring you to us?

Please tell us why you’ve been referred to us?

In the event of an emergency please contact:

Phone Number:

How would you like us to confirm your future appointments?
SMSEmailPhone

Heart Condition (surgery/disease/attack)Heart Murmur or Rheumatic FeverHigh Blood PressureArthritis/RheumatismArtificial JointsFainting or Dizzy spellsEpilepsy or Seizures

Chemotherapy or Radiation treatmentCancer/ TumoursCorticosteroid therapyHIV/AIDSThyroid problemsNervous/ AnxietyHepatitis A B C D ENeurological Disorders

Stomach ulcersDiabetesSinus troublesAsthma or HayfeverKidney or liver troublesAnaemia or other blood disordersAllergies to anaesthetics/penicillin/medications/latex

Do you have any ALLERGIES? NOYES
[group haveallergy]
If yes, please list
[/group]

Do you have or have you had previously any disease, condition or problems not listed? NOYES
[group havedisease]
If yes, please list
[/group]

Your medical doctor’s name:

Medical doctor’s number:

Are you taking any medications, drugs or pills? NOYES

Are you taking or have you previously taken any bisphosphonate medications (e.g. Fosamax, Zometa, Didronel, Relast, Boniva, Atelvia, Aclasta, Actonel, Aredia, Binosto, Skelid)? NOYES

Have you been admitted to hospital before? NOYES

[group admithospital]
If yes, for what?
[/group]

Do you smoke? NOYES

[group smoker]
If Yes, how much? Number of times a day: For how many years:
[/group]

Do you drink alcohol? NOYES
[group alcoholconsume]
If Yes, how much per week?
[/group]

Are you pregnant? NOYES

[group pregnantyes]
How many months:
[/group]

Nursing? NOYES

Person responsible for paying the account (if not yourself)?

Do you have private dental health cover? NOYES

[group privateyes]
If so which company?
[/group]