Patient Data Form

Patient Information Form

To assist with our service provision, please complete answers to all questions that apply to you. Thank you

PATIENT DETAILS

First Name *

Last Name *

Preferred Name

Date of Birth *

Occupation

What procedure or concern are you consulting for

CONTACT DETAILS

Mobile Phone

Email *

Postal Address

Postcode

City / Suburb

State

NEXT OF KIN

Name *

Mobile Phone *

Who is your regular GP?

MEDICARE

Medicare Card No.

Expiry

Reference number

PRIVATE HEALTH INSURANCE

Do you have private health insurance *

YesNo

Health fund name

Membership Number

Aged Pension / DVA / Defence

Aged Pension Card Number

Expiry(mm/yyyy)

Department of Veterans' Affairs Membership Number

Card Type

GoldWhite

Department of Defence PM Keys Number

Medical conditions and treatment

If you have selected any of the above, please describe your treatment

Please select which of the following medical issues you have experienced

Deep vein thrombosis (blood clots in the leg)Pulmonary embolism (blood clots in the lung)Difficulty with AnaesthesiaInfections (such as MSAR)Heart Attack

If you have experienced any of the above, please describe your treatment

Please list any major operations you have had

Have you suffered any major complications from past operations

If you have a condition not listed above, please describe it

Please list any medication you are currently taking (prescription, over the counter or herbal). Please take special care to list any blood thinners such as aspirin, warfarin and fish oil.

Please list any allergies you may have, specifically medication or latex allergies.

Habits

Alcohol

Never

OR average number of drinks each day

Smoking

Never

OR average number each day

If you have quit in the past 5 years, when did this happen?

Expectations

If you are here for a cosmetic consultation, what concerns about your appearance have brought you today? What are you hoping to achieve with surgery?

SIGNATURE

I consent to the use and disclosure of this information between Queensland Plastic Surgery staff and third parties, including Medical or Nursing Staff who are involved or likely to be involved in my care. I consent to my personal information being used for secondary purposes; ie. accreditation, quality assurance programs, clinical audits and billing procedures from our Practice. I understand that it is my responsibility to ensure that my personal information is accurate, complete and up-to-date.

Would you like to receive our occassional email newsletter for special promotions and education articles?

Yes

Patient Signature

Draw signature|Type signatureClear

Today's Date

Please check the box below to confirm you are a real person—this helps us keep your information safe and secure. *

Save and Complete Later