WelcomePlease take a moment to complete the following information for us so that we can ensure the best of care. Name * First Name Last Name Email * Phone (###) ### #### Text Address Address 1 Address 2 City State/Province Zip/Postal Code Country Private Health Insurer Do you have Dental Cover? Yes No Are you covered by the following? DVA ADF / BUPA WorkCover Emergency Contact First Name Last Name Emergency Contact Phone (###) ### #### Relationship to you Do you have any existing illness(es)? Are you currently undergoing any medical treatment? Please provide details Have you ever had any of the following? Please tick all that apply High Blood Pressure Low Blood Pressure Arthritis Bleeding Disorder Diabetes Stomach Ulcers Steroid Therapy Artificial Joints Eating Disorder Liver Disease Asthma / Breathing Disorders Tuberculosis Rheumatic Fever Stroke Heart Surgery / Heart Attack Allergies / Hives Emphysema Osteoporosis Epilepsy Anaemia Thyroid Disease Heart Complaint Cancer Kidney Disease Contact with HIV / AIDS Hepatitis A, B or C Stomach Ulcers Sinus Therapy Who is your Regular GP? First Name Last Name GP Practice Name Your GP's Contact Number (###) ### #### Who is your regular Dentist? First Name Last Name Dental Practice Name Your Dentist's Contact Number (###) ### #### Medications * Please list all medications you are currently taking including the dose and frequency. Include prescription, over-the-counter, herbal supplements and recreational drugs. If none, please write N/A If you are a smoker, how many cigarettes do you currently smoke per day? If you are an ex-smoker, how long ago did you quit? Are you allergic to any medication or materials? Eg: Penicillin / Latex Thank you!
