New Patient Form

Before attending your first appointment with Dr Yas Edirisinghe, please complete the form below to provide the team with information relevant to your condition and medical history. For any questions about preparing for your consultation, please contact the practice.

"*" indicates required fields

General Information

Name*
DD slash MM slash YYYY
Address*

Emergency Contact Information

Medicare Details

DD slash MM slash YYYY

Private Health Insurance

Medical History

Have you in the past been diagnosed with, prior treated for, or currently on treatment for any of the following? (please tick all that apply)
Do you have any allergies?*
Do you have any metal hypersensitivity or sensitivity to jewellery?*
Do you take any blood thinners/ antiplatelets/ anticoagulants?*
Smoking History*
Have you ever had any surgery?*
Have you had any problems with anaesthetics (general or local)?

Procedures

Which procedure/s would you like to discuss?
Consent*
DD slash MM slash YYYY
This field is for validation purposes and should be left unchanged.

Advanced, patient-centred technology for better outcomes.

Contact us via the contact page or chatbot available across our website and Dr Yas will respond promptly.

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