FOR NEW PATIENTS

Patient Registration

Complete this registration form ahead of your initial consultation. It gives our team the information they need to provide safe, personalised TMJ care. All information is kept confidential.

Sections marked optional can be skipped if not relevant. If you are unsure about any medical question, leave it blank and discuss with the surgeon at consultation.

Personal details

Insurance & ACC

Do you have insurance?
Is this an ACC claim?

Emergency contact

Doctor & medical information

Medical history

If you answer Yes to any of the questions below, please describe in the box that follows.

Are you currently taking any medications?
Do you have any allergies?
Have you had any serious illness?
Have you been hospitalised in the past?

Do any of the following apply to you?

Tick all that apply.

Conditions

Lifestyle

Are you pregnant?
Do you smoke?
Do you drink alcohol?

How did you hear about us?

Referral source

Consent & accuracy

By submitting, you agree to be contacted by Auckland TMJ Centre about your enquiry. We do not share your information with third parties.

Prefer paper or phone? Call the practice and reception will work through the form with you.

Same surgeons

OMS Specialists

When surgery is required, it is carried out at OMS Specialists, our co-located oral and maxillofacial surgery practice. Same surgeons, same accredited facility, full-scope surgical care across jaw, facial, oral, and skin conditions.

Visit OMS Specialists