SYDNEY ORAL MEDICINE YOUR DETAILS (Please print clearly)
Title. . . . . . . . . .Surname………………………Given Names…………………….…….
Date of birth………….……………………………. Gender: □ Male □ Female
Address………………………………………………………………………………….…
Suburb……………………………….State……………Postcode….….…
Telephone:.(H)………………………………….(M)………………………………………
(B)………………………………………Occupation.
Email……………………………………………………………………………………….
NEXT OF KIN/PERSON TO CONTACT IN EMERGENCY
Name:………………………………….Relationship to patient………………………….
PRIVATE HEALTH INSURANCE & MEDICARE
Do you have Private Health Insurance with Dental cover? □ Yes □ No
Medicare card no…………………………….Ref.no………………Expiry date…………
Person responsible for accounts (if not self)……………………………………………….
Are you happy for us to confirm your appointments via SMS on your mobile?
If not, would you prefer: □ Email □ Phone Referring Doctor:
. YOUR MEDICAL HISTORY
Please tick “Yes” if you have now, or have had in the past, any of the following:
Heart condition or murmur □ Yes □ No Muscle, bone, joint problems □ Yes □ No
Rheumatic fever □ Yes □ No Immune system problems □ Yes □ No
High blood pressure □ Yes □ No Gastrointestinal problems □ Yes □ No
Bleeding problems □ Yes □ No Urogenital problems □ Yes □ No
Respiratory problems □ Yes □ No Liver problems □ Yes □ No
Nervous system problems □ Yes □ No Cancer □ Yes □ No
Thyroid problems □ Yes □ No Pregnancy □ Yes □ No
Diabetes □ Yes □ No Smoking □ Yes □ No
Infectious diseases □ Yes □ No Alcohol □ Yes □ No
Osteoporosis □ Yes □ No Betel nut use □ Yes □ No
Medications…………………………………………………………………………………
………………………………………………………………………………………………
Have you ever been prescribed any of the following medications? Zometa™,
Pamidronate™, Bonefos™, Actonel™, Fosamax™ .
Hospital admissions……………………………………………………………………….
………………………………………………………………………………………………
Allergies…………………………………………………………………………………….
.…………………………………………………………………………………………….
Other…………………………………………………………………………………….…
FAMILY DOCTOR’S DETAILS
Doctor’s Name…………………………………………………………………………….
Address…………………………………………………………………………………….
Telephone………………………………………………………………………………….
CONTRACT IDENTIFICATION The benefits outlined in this booklet are available to plan members under Contract Number 84444: Division Numbers, Active Employees Division 1 -Elementary Principals and Vice-Principals -Secondary Principals and Vice Principals -Professional Student Services Personnel - OSSTF, Unit A -School Office staff, Classroom Support staff and Central Administrati
Section1 Student Forenames: Last Name: Date of Birth: Place of Birth: Parental Address: Fathers Address if Different: Phone Number: Phone Number: Email Address: Email Address: Name and Address of Current GP: Does your child take any regular medication, Does your child have any known allergies? Is your child on the BUPA School Medical Insurance