New patient form

New Patient Form

PATIENT DETAILS

First name *

Last name *

Preferred name

Date of birth *

Gender *

Occupation *

MEDICATIONS

Do you take any blood thinners? *

YesNo

Please list all the blood thinners that you take:

Do you take any diabetes medications? *

YesNo

Please list all the diabetes medications that you take:

Do you take a GLP-1 receptor agonist or diabetes/weight loss injection? Examples include Ozempic, Mounjaro, Wegovy, Trulicity, Victoza, Saxenda, Byetta, Bydureon. *

YesNo

Please list which medication you take:

Do you take any over the counter drugs/supplements (e.g. fish oil, herbal supplements)? *

YesNo

Please list all the over the counter drugs/supplements that you take:

SURGERY PREFERENCES

Some patients, particularly those who have had surgery before, already have a preference for how they would like to have their surgery. You can either have your surgery awake under local anaesthetic, or you can have your surgery asleep under a light general anaesthetic (similar to a "twilight" sedation). We will discuss these options with you in more detail, but please indicate if you have a preference already: *

I prefer to have my surgery awake under local anaestheticI prefer to have my surgery asleep under general anaestheticI don't have a strong preference

MEDICAL HISTORY

Do you smoke? *

YesNo

Do you have any blood-borne diseases (e.g. HIV, Hepatitis)? *

YesNo

Medical conditions

Allergies

CONTACT DETAILS

Home address *

Mobile phone *

Email address

MEDICARE DETAILS

Medicare card number *Remove any spaces before submitting

Reference number *

Expiry *

If completing this form for a child under 16, please complete below:

Parent/Guardian's Medicare card numberRemove any spaces before submitting

Parent/Guardian's Reference number

Parent/Guardian's Date of birth

DVA CARD

Do you have a DVA (Department of Veterans' Affairs) card? *

YesNo

DVA card number

DVA card type

GoldWhiteOrange

PRIVATE HEALTH INSURANCE

Do you have private health insurance? *

YesNo

Health fund

Membership number

Have you already paid your private health insurance excess/been admitted to hospital as an in-patient this year?

YesNo

NEXT OF KIN DETAILS

Name

Relationship

Mobile phone

HEALTH CARE TEAM

Referring Doctor *

Clinic Name *

Usual GP

GP Clinic

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