Specialist Oral, Jaw & Facial Surgeons for Auckland

Patient Registration Form

    Insurance Details

    Do you have medical or dental insurance?*

    Have you had your insurance for 12 months or more?


    Emergency Contact Details

    Medical Details

    Who is your GP?

    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 anaesthetic?*

    Please tick if you 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 VALVE 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?*

    Are/could you be pregnant?*

    Have you or any of your family or friends have travelled overseas recently?*

    If yes, to which country have you / they travelled?

    Additional Details

    Do you have any individual requirements? If yes, please provide more details.



    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?*

    If you have answered yes please provide more details

    How did you hear about us?*

    Please review and confirm your answers.
    We require 48 hours' notice for all cancellations or 30% of that appointment will be charged.
    For insurance purposes, it may be necessary to release health information to your insurance provider to obtain your prior approval.
    I acknowledge that my health information may need to be released to the insurance provider and give my informed consent for this to occur.

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