Form Test - Dr Kristian van Mourik

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Bondi Junction & Lindfield, Sydney

(02) 9416 4809
admin@kristianvanmourik.com.au

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Home
About Us
Procedures
Locations
- Lindfield
- Bondi Junction

Referrals
New Patients

Your Details

MrMrsMsMissMasterDr

First Name *

Surname *

Date of Birth

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Email Address *

Medicare Number

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First Name *

Surname *

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Patients under 18yrs or under Parent Medicare Card

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Your Details

Your Details

Have you had any serious illness, operation, or hospitalisation? (eg. cardiac, joint replacements, cancer, stroke etc) *

Are you taking any medicine(s), non-prescription, vitamins, or natural remedies? *

Are you taking or have you ever taken Bisphosphonates (i.e. Prolia, Fosamax, Actonel, or Zometa)? *

Please tick any applicable conditions:Heart condition (including any valves, artificial valves, pacemaker, or heart murmur)Blood disorder such as anaemia or haemophiliaAsthmaDiabetes – Type 1Diabetes – Type 2Hepatitis, jaundice, liver diseaseThyroid problemsOsteoporosisArtificial joint replacement (knee, hip, shoulder, etc.)Anxiety, depression, or mental health conditionNeuromuscular condition (e.g. Myasthenia Graves or Lambert-Eaton)CancerRadiation therapy to head, neck, jawAllergiesN/A

Specify if you ticked any above answers

Do you smoke or vape?

Do you consume alcohol?

Are you pregnant, nursing, or trying to become pregnant?

Consent

I consent to the collection of my personal and health information in accordance with the Australian Privacy Act including the use of AI-powered scribe to assist in documenting my medical history, treatment details and other important information during my consultation and treatment. I have properly disclosed my personal details and medical history. I understand the information provided will be kept confidential and may be used in the following ways.

Billing and administrative purposes including compliance with Medicare Australia
Disclosure to other health care professionals, including treating doctors & specialists outside this medical practice. This can occur through referral to other doctors and referral for medical tests.
I have read and understand this whole form. I understand it is my responsibility to fill out the form correctly and accurately.
Clinical images may be used for teaching purposes and are deidentified.

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I have read and agree to the consent statement above.

Please do not fill in this field.

Home
About Us
Procedures
Referrals
New Patient Form
Locations
Contact

We provide Oral and Maxillofacial surgery in Sydney, including wisdom tooth removal, dental implants, corrective jaw surgery, TMJ surgery, and oral pathology. Care is delivered with a focus on surgical excellence, clear information and the highest standard of patient care.

LINDFIELD
Suite 5,12 Tryon Rd,
Lindfield NSW 2070

BONDI JUNCTION
Suite 104, 568 Oxford St,
Bondi Junction NSW 2022

DEE WHY
Delmar Private Hospital 58 Quirk St,
Dee Why NSW 2099

(02) 9416 4809

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