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Please only complete this form once you have a booked appointment.
Title MrMrsMsMissDrProfOther
First Name (required)
Known as (if different from above)
Address (required)
Phone Number (required)
Surname (required)
Date of Birth (required)
Email (required)
Phone Number (secondary option)
Medicare Number (required)
Medicare Reference No (required)
Expiry Date (required)
Private Health Insurance YesNo
Private Health Insurance Fund Name (if applicable)
Aged Pension Card (if applicable)
Veteran Affairs Number (if applicable)
Work Cover Date of Injury (if applicable)
Private Health Insurance Membership No
Aged Pension Card Membership No
Expiry Date
Employer
Employer Address
Insurer
Claim Number
______________________________________________________________________________________________________________________________
NEXT OF KIN
Name
Relationship to you
Contact Number _______________________________________________________________________________________________________________________________
REFERRAL DETAILS
Referring Doctor (required)
Contact Number
Practice Name (required)
Usual GP (if different from that already supplied)
MEDICAL QUESTIONAIRE
Have you ever suffered from Heart AttackAnginaOther Heart DiseaseHigh Blood PressureStrokeTIA (mini strke)AsthmaEpilepsyBlood Clots in Legs (DVT) or lungs (PE)Diabetes
If you have diabetes, is this controlled by DietTabletsInjections
Do you take any blood thinning medications (eg Aspirin, Warfarin, Clopidogrel, Plavix, Pradaxa, Xarelto, Eliquis) YesNo
Please provide a list of all medications, including supplements and herbal remedies (eg fish oil) you are taking
Alcohol intake per day
Are you a smoker? current smokerex smokernever smoked
If current smoker, how many per day?
If ex smoker, when did you quit?
Number per day
Have you ever had any major operations or serious illness not listed above (if yes please provide details): Are you allergic to anything? YesNo If so, please list ________________________________________________________________________________________________________________________
PHOTOGRAPHY CONSENT
Clinical photography and or video during surgery may be taken to assist in your care. These become part of your confidential medical record. We would also like to ask your permission to use these photos/videos for educational purposes. Any material used for educational purposes are de-identified. Your name or images of your face are NOT used and as far as possible any identifying factors are masked.
Do you consent to for clinical images being used to teach other health professionals (doctors, nurses and healthcare or medical students)? YesNo
Do you consent to these images being used for publication in medical journals? YesNo
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