Patient Information Please fill in the information below. ALL fields are required. Submitting this form acknowledges all information is correct and Consent to our policies is provided.If you have any questions, please contact our team on 32263800.Only complete this form once you have made and appointment. Submitting this form will NOT prompt an appointment booking Title Title Mr Mrs Miss Ms Other Name First Name Last Name Date of Birth MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Mobile phone number (###) ### #### Phone - home/ work (###) ### #### Email * Messaging If we are not able to contact you, would you like us to leave a message with whoever answers the phone yes no Do you have Private Health insurance Yes No Medicare Card Number Exp Ref No: Are you a DVA card holder No Gold White DVA Number DVA Card Exp Do you have Private Health Insurance for Hospital cover Yes No Fund Name Membership Number Next of Kin First Name Last Name Phone Number Relationship Do you have a current Referral GP referral must be within 12 months Specialist referrals must be within 3 -months You can not be seen without a referral Yes No Referring Doctor First Name Last Name Referring Doctor Address Referring Doctor Phone (###) ### #### General Practitioner If different form your referring Doctor General Practitioner Address General Practitioner Phone (###) ### #### Any current / Previous Medical Conditions Any Medications Allergies Smoking Status Do you currently smoke, or have smoked within the last 3 months This includes Vaping / E-Cigarrettes Yes - Currently smoking Yes - within 3 months Ex-smoker - Quit more than 3 months Non smoker Are you a Diabetic No Yes - Insulin dependant Yes - Medication only (Type 2) Blood Thinning Medication Do you take any medication that prevents clotting / this your blood No Yes - Aspirin only Yes - Warfarin Yes - Other anticoagulation (Apixaban, Xarelto or other) Supplements - Fish oil, Krill Oil, Garlic, Tumeric, other Photography Photos are an important aspect of providing clinical care. Clinical photos are often used in Theatre and after to proved the best care possible.Do you agree to Clinical photos being taken clinical care, record keeping and medicare requirements. Dr Green may need to share phots with other health professionals involved directly with your care (you will be informed of this if required). Photos are not published on any external service without prior written consent and will not be shared with any other 3rd party without your prior written consent Yes I consent to Phots being taken for clinical use No I do not consent and I will discuss this with Dr Green at my appointment Fees Consultation fees do apply and need to be finalised at the time of your appointment. Fees for Radiology and pathology are not under the control of Dr Green. These are payable to radiology and Pathology companies as per their policies. If you have questions about additional fees, please discuss with Dr Green when request forms for these services are provide. Surgical fees will be provided to you as part of informed financial consent prior to your surgery. Our fees policy will be explained prior to your surgery which may require non-refundable deposits, full payment prior or delayed payment of rebates if billed through Medicare or your health fund. I agree to Fees associated with my initial consultation and acknowledge radiology and pathology fees are separate to Dr Green I do not agree to fees and would like to discuss with Dr Greens Team. Privacy Our staff will not disclose this information to any third party. Your information is stored on a secure password protected information system. Onward referral to another specialist will require duplication of this form, your record and test results. If results are not received by the practice, our staff may call the organisation that performed the tests to receive a copy by mail, fax or electronic methods. Your records and information may be kept by your doctor at another location. Your information may be used for billing purposes including bad debt managent. If you do not give permission for the above please let our reception tema know. Access to your medical records may be allowed in accordance with the appropriate section of the National Privacy Act 1988 Do you acknowledge you have read the above information and the information you provided is accurate? By submitting this form you you agree to email notification of our staff and proved your consent to the above information. I agree with the above information and provide consent Consnet confirmed I do not consent Thank you!
