Patient Registration

For the team at OMFS to properly treat you or your family, the details of your medical history is needed. Having your medical history can enable our surgeons to treat you with optimal and personalised care.

For your convenience, we have our patient registration form available below:

  • Patient Details

  • Medicare

  • Insurance

  • Emergency Contact

  • Bill Payer Details

    Only complete this section if someone OTHER than the patient is responsible for the account
  • Referrer Details

  • If yes, please provide their details below
  • Medical History

  • Certain groups are at a high risk of being infected with HIV, Hep B and Hep C. Are you in such group?
  • If YES, please list; If NO, please state No.
  • If YES, please list;
  • If YES, please list;
  • If YES, please list;
  • Your Health Information and Our Privacy Policy

    In accordance with the Australian Privacy Principles contained in the Commonwealth Privacy Act 1988 (Privacy Act) and applicable State legislation.
    OMFS respects your right to privacy and thus has systems and processes in place to ensure it complies with the Australian Privacy Principles.
    This statement is a summary of the practice’s privacy policy.
    The complete policy is available in the waitingroom or upon request.

    OMFS collects information about you for the purpose of providing health services to you. Personal information such as yourname, address and health insurance details are used for the purpose of addressing accounts and sending relevant correspondence, as well as processing payments and writing to you about our services and any issues affecting your health care.

    OMFS may disclose your health information to other health care professionals or third parties, or require it from them if, in our judgement, it is necessary in the context of your care.
    Your health information may also be used for research purposes, in study groups or at seminars; however, in such situations, your personal identity will not be disclosed without your consent.

    You may choose not to provide OMFS with information relevant to your care. In this instance OMFS may not be able to provide a service to you, or the service we are asked to provide may not be appropriate for your needs.
    Importantly, if you do not provide information that may be relevant to your care or that is otherwise requested by OMFS, you could suffer some harm or other adverse outcome.

    Your medical history, treatment records, x-rays and any other material relevant to your care will be stored by OMFS.
    The privacy policy sets out how you can access your records or seek correction of your records. It also specifies how you can report suspected privacy breaches and how OMFS will deal with such a situation.

    As part of its electronic records system, OMFS may rely on cloud storage providers located outside Australia. OMFS will comply with its obligations under Australian privacy laws in relation to all offshore storage situations.

    The OMFS Business Manager can be contacted at the practice during business hours on 03 9347 3788 or emailed at if you have any concerns or questions about a privacy matter.
  • Please sign this form as confirmation that you have read and understood our Privacy Policy, and consent to the use of your information in the ways outlined.(If the patient is under 16 years of age, a parent or guardian must sign on their behalf)
  • DD slash MM slash YYYY
  • This field is for validation purposes and should be left unchanged.