• R. J. Begg and Associates R. J. Begg and Associates
    Our beautiful treatment centre
  • R. J. Begg and Associates R. J. Begg and Associates
    Full digital X ray facilities
  • R. J. Begg and Associates R. J. Begg and Associates
    Specialised Instrumentation
  • R. J. Begg and Associates R. J. Begg and Associates
    Find us here - walking distance to Elmwood shopping area
  • Reception R. J. Begg and Associates
    Full digital X ray facilities
  • Treatment Room Treatment Room
    State of the art treatment facilities
  • Treatment Room Treatment Room
    State of the art treatment facilities
  • Lab Lab
    Modern Sterilisation Equipment
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Patient Online Registration

Personal Information

Mr    Mrs   Miss   Ms
Male   Female

Contact Details


Emergency Contact


Insurance

Yes   No  

If yes, please specify:


Your Medical History

Yes   No  
Yes   No  
Rheumatic Fever
Epilepsy
Heart Trouble
Anaemia High
Blood Pressure
Asthma
Kidney Problems
Arthritis
Gastric Problems
Bronchitis / Chest Problems
Cold Sores
Severe Headaches
Depressive Illness
Yes   No  

If yes, please specify all medicaion:

Yes   No  
Yes   No  
Yes   No  
Yes   No  
Yes   No  

Yes   No  

If yes, please specify how many months?



Acknowledgement

To my knowledge the above is a true and accurate account of my medical history and personal details.

Agreement to pay:


I undertake to pay any charges that I incur. If I have claimed to have my treatment covered by a third party, eg. ACC or Medical Insurance and the claim is not accepted within 3 months I understand that I am liable for the full cost of treatment received. In the event of non-payment of my account I will be liable for any recovery costs, legal fees and commissions that may be incurred in obtaining payment of my account. Additional costs to those estimated may be applicable eg. For additional follow up, urgent or emergency care or additional investigations.

Consent to email communication:


I consent to my personal details and clinical notes to be communicated to my referrer via email (unsecured) and where applicable, to other health care providers or third party (eg. GP, ACC, insurance provider) as part of my ongoing health care.


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