Click to download Patient Information Form

    Patient Information

    Patient Name *

    Date of Birth *

    Sex *

    Address

    Suburb

    Postcode

    Phone (L)

    Phone (M)

    E-mail

    Occupation

    Medicare

    Reference

    Expiry Date

    Parent’s Medicare Card Details (if under 18 years of age – required for Medicare rebate) Parent Name

    DOB

    Medicare #

    Ref. #

    Expiry Date

    Patient 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

    Next of Kin:

    Relationship:

    Phone

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

    Other Medical Conditions...

    Previous Surgical Procedures...

    Current Regular Medications...

    Allergies...

    Are your currently taking any weight-loss medications (such as Ozempic)?:

    Any difficulties with anaesthetics in the past?:

    Current weight?

    Current height?

    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
    Phone consultations require payment 1 business day prior. All other Consultation fees are to be paid on the day of consultation (by either EFT, Visa and Mastercard).
    All surgical fees must be paid 2 weeks 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 medication information about them and to be able to communicate that medical information to another medical or dental practitioner.
    The following form must be signed if you are willing for Sunshine Coast Oral, Facial & Implant Specialists to obtain such information and to liaise with other health practitioners concerning your condition. By signing this form, you give permission for your Surgeon and Sunshine Coast OFIS to:
    1. Obtain medical information about 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 my treatment, and to the use of same by the doctor in advertising, scientific papers, or presentations.

    Name *

    Date *

    USE OF ARTIFICIAL INTELLIGENCE (AI) IN YOUR CARE
    As part of our commitment to providing high-quality and efficient care, our clinic uses AI technologies to assist with clinical documentation. We use the Heidi platform, which includes an AI tool that listens to consultations and generates clinical notes, as well as AI transcription software to transcribe letters dictated by your doctor. These tools help streamline documentation and support accurate communication with other healthcare providers.
    Your personal information may be used in this process but is handled securely and in accordance with privacy regulations. By proceeding with care at our clinic, you are acknowledging and consenting to the use of these AI tools.

    Signature of Patient:

    Your Full Name *

    Date *

    Name of parent or guardian: