Medicare / Insurance / DVA / Work cover details
Do you have Private Health Insurance?*
Do You have hospital cover?*
What level of health cover do you have?*
Do you have coverage under Veterans Affairs (DVA)?*
DVA Gold / White Card holder
Are you covered under workers compensation for this treatment?*
Have you had a FULL MOUTH xray (OPG) / CT scan of your face in the past 12 months?*
Have you been diagnosed with any of the following conditions?
Current Medications / Treatments / Past treatments
Have you ever taken medications for osteoporosis / bone density / bone cancer?*
Have you ever BLOOD THINNING Medication? (aspirin / warfarin)?*
Have you ever suffered excessive bleeding following a surgical procedure?
Please list any ALLERGIES you have INCLUDING MEDICATIONS:
For females :Are you / or may be pregnant?