Patient Registration - Dr Nathan El-Atem

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This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Date of birth(Required)

Occupation

Phone number(Required)

Email(Required)

Address

Street Address Suburb Postcode

Next of kin name

First Last

Next of kin contact number

GP Name

First Last

GP Clinic name

Dentist Name

First Last

Dentist Clinic name

Medicare number

Medicare reference number

Medicare expiry date

Private health fund name

Private health member number

Private health reference number

Hospital cover:

Yes

DVA card number

DVA card colour

DVA card expiry

Worker cover claim:

Yes

Medical history or conditions

Medications including tablets, injections (including 6 monthly osteoporosis injections), blood thinners, diabetes medications:

Allergies or bad reactions to medications/tapes :

Are you pregnant?

Yes

Do you smoke?

Yes

Any major operations in the last 5 years? What operation, what hospital, any issues:

Weight:

Height:

Consent

Privacy, Consent, and Financial Agreement

This practice collects and handles your personal and health information in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles (APPs). We require your personal details and medical history to properly assess, diagnose, and provide medical care. By signing this form, you consent to this practice handling your information to provide quality healthcare, including associated administrative and billing tasks. You grant permission for medical information to be obtained from external sources—such as your GP, Dentist, other specialists, hospitals, pathology labs, or imaging providers—to assist with your treatment. You also consent to the use of clinical photography for documentation, procedure planning, and follow-up. We may send your details to another clinician as correspondence or a referral. We may discuss or present your case with other clinicians to obtain a second opinion on your behalf or for teaching purposes. Any medical details, images, or radiographs used in these discussions or presentations would be de-identified prior to use. You have the right to request access to your personal information held by this practice at any time.

To ensure clinical accuracy, this practice utilises an Artificial Intelligence (AI) scribe during consultations. The AI scribe captures audio to generate a text-based clinical draft, which is then reviewed and edited by your surgeon to ensure it is correct. All audio data is deleted immediately after the written note is generated, and information is stored only as text within your clinical record. By proceeding, you acknowledge that you have reviewed our fee policy and agree to pay the costs associated with your consultations and any surgical procedures performed.

Fee Policy: The fee for your consultation is payable on the day. The expected fees for the consultation and some common procedures are available at the Jaw Surgeons Brisbane fees page. Patients who fail to attend appointments without 2 hours prior notice will incur a non-attendance fee of $50. By signing this form, you are agreeing to the fee policy.

Consent:(Required)

I have read the above fee policy and privacy statement. I consent to the taking and use of my medical records as described, including the use of an AI scribe. I have viewed the fees at https://jawsurgeons.com.au/fees/ and agree to pay the costs of consultations, and any surgical procedures performed.

Patient Signature(Required)

Date(Required)

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