Registration Form

New Patient Registration Form

Please use this form to register for treatment at JVC. This form will provide us with important details regarding your contact information and any health details. These details are essential before proceeding with endodontic treatment.

Patient Information

Mr / Mrs / Ms / Miss / Other*

Surname*

Given name*

Preferred name*

Date of Birth (DD/MM/YYYY)*
/ /

Patient Contact

Address*

Suburb*

Postcode*

Phone (Mobile)

Phone (Home)*

Email*

Confirm Email*

Health Insurance Fund*

Patient Series Number
0123456

  Check this box if the treatment is going to be paid by a third party

  Check this box if you are completing this form on behalf of the patient

Private & Confidential Medical Information

Certain medical conditions and medication use require special precautions during dental treatment; so please answer the following as accurately as possible for your safety.

What is your medical doctor's (GP) name and suburb?*

Please list any medical conditions you have or you have had in the past*

DiabetesHigh Blood PressurePacemakerLiver DiseaseThyroid ProblemsRheumatic FeverAsthma
HepatitisHeart ProblemsEpilepsyArtificial ImplantsHIV / AIDSNervous DisorderNone of the above

Have you had any recent surgery within the last 2 years?*
YesNo

Please list any medication you are currently taking*

Have you ever had an unusual reaction to Anaesthetic?*
YesNo

Please list any allergies (Penicillin, Latex, Medication)*

Do you bruise or bleed easily?*
YesNo

Are you pregnant?*
YesNo

Are you breastfeeding?*
YesNo

Do you have any medical conditions that you wish to discuss with the doctor in private?*
YesNo

Any additional information that we need to know about your health?*

Are there any aspects of the root canal treatment that concern you?*

PLEASE NOTE: IT IS IMPORTANT YOU ADVISE YOUR ENDODONTIST OF ANY CHANGES TO YOUR HEALTH BEFORE EACH VISIT

Emergency Contact

Emergency Contact Full Name*

Emergency Contact Phone Number*

Endodontic Treatment

PLEASE TAKE THE TIME TO READ THE FOLLOWING PARAGRAPH

Routine Endodontic (Root Canal) Treatment has a very high success rate (studies indicate success rates of 90% to 95%), however cases that are referred to an Endodontist are usually not routine, and it may not be possible to predict the outcome of the treatment. Occasionally a tooth which has had endodontic treatment may require retreatment, surgery or even extraction. Factors that can contribute to complications or failure of endodontic treatment include presenting condition of the tooth; previous treatment is done on the tooth; type of bacteria involved in any infection; anatomy of the tooth and mouth; limitation of our instruments and procedures; your general health and your cooperation during the treatment. Fees Range from $1200.00 – 2700.00 when treatment commences. If you would like a printed estimate, please ask the Endodontist before starting treatment.

  I have read carefully and understand the statement above

  I have answered these questions honestly and to the best of my knowledge

Payment Information

PLEASE NOTE: Payment in full is required on the day of your treatment. EFTPOS, credit card (AMEX, Mastercard, Visa) & HICAPS facilities are available. If for any reason, you cannot pay the account in full on the day, please inform us before your appointment. An overdue account will incur additional charges.