Click to download Patient Information Form

    Patient Information

    Patient Name *

    Date of Birth *

    Sex *

    Address

    Suburb

    Postcode

    Phone (L)

    Phone (M)

    E-mail

    Occupation

    Next of Kin:

    Relationship:

    Phone

    Medicare

    Reference

    Expiry Date

    Health Fund

    Member

    Waiting PeriodHave you served your waiting period?

    Hospital CoverDo you have hospital cover?

    Dental & MedicalAre you covered for bot dental & medical procedures in Hospital?

    DVA

    Workcover

    Medical HistoryPlease indicate if you have any of the following...

    Other Medical Conditions...

    Previous Surgical Procedures...

    Current Regular Medications...

    Allergies...

    Are you able to take NSAIDs (Nurofen)?:

    Do you take blood thinners?:

    Drugs for your Bones?:

    Have you had radiotherapy to the head or neck?

    When and where have you had radiotherapy?

    Are you a Smoker?

    How many Cigarettes per day?

    Do you drink Alcohol?

    How many glasses do you drink (per week)?

    Could you be pregnant?

    Name of GP?

    Name of Dentist?

    ACKNOWLEDGEMENT OF FEE POLICY
    Consultation fees are to be paid on the day of consultation (by either EFT, Visa and Mastercard).
    All surgical fees must be paid 1 week prior to surgery to avoid your procedure being cancelled.
    The above information is correct to the best of knowledge and I understand the conditions of payment.

    Signature of Patient:

    Your Full Name

    Date

    Name of parent or guardian:

    CONSENT TO COLLECT PATIENT INFORMATION
    Australian Privacy Laws dictate that a person’s written consent is required for a health professional to obtain medical information about them and to be able to communicate that medical information to another medical or dental practitioner.
    The following information must be confirmed if you are willing for Dr Trent Lincoln to obtain such information and to liaise with other health practitioners concerning your condition.
    By agreeing to this form, you give permission for Dr Trent Lincoln and Sunshine Coast OMS to:
    1. Obtain medical information about me from other medical or dental practitioners, including consultation notes and results of tests or investigations performed by other medical or dental practitioners that pertain to my medical condition.
    2. Communicate with other health professionals directly involved with my medical condition.
    3. Communicate with the referring practitioner concerning my medical condition.
    4. I consent to the taking of clinical, de-identified photographs and x-rays before, during and after treatment, and to the use of same by the doctor in advertising, scientific papers or presentations.

    Name

    Date

    Appointments Available

    Request a booking online.