Level 11, 225 Wickham Terrace
Brisbane, QLD 4000

T 07 3839 7646
F 07 3839 7663
E reception@faciomax.com
New Patient Information
Male Female

Contact Details

Doctor Details:

Medicare & Health Insurance details:

Medicare Details:

Private Health lnsurance:

Yes No Yes No

Veteran Affairs:

TAC/Workcover

Medical Summary

Rheumatic fever
Diabetes
Heart problems
Heart murmur
Epilepsy
Kidney disease
Hepatitis/HIV/Blood borne diseases
Respiratory Problems (eg. Asthma)
High / Low blood pressure
Osteoporosis
Stomach reflux/ulcer
Excessive bleeding
Radiotherapy to Head/ Neck/ Facial regions
Nervous/ Anxiety conditions
Prosthetic or other implant
Penicillin
Aspirin
Latex
Elastoplast or tapes
Any Other allergies
Yes No
Yes No
Yes No Yes No
Yes No
PRIVACY STATEMENT Our practice respects your right to privacy and compries with the regisration relating to the collection, storage, use and disclosure of health information. For more information please ask for the Privacy Statement handout'
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