Confidential Patient InformationWelcome to out practice. Our aim is to provide you with the best possible healthcare. Please complete all sections and read the Personal & Health information Consent section at the end of this form. Should you have any queries speak one of our team members, or Dr Sharp.Personal DetailsMsMissMrsMrMasterDrProfOtherDate Of Birth: Date Format: DD slash MM slash YYYY Given Name:Surname:Address:HomeWorkMobileEmail Please select:RetiredUnemployedEmployedOccupationClaim DetailsMedicare number:Ref #:Do you have Private Health Insurance? Please select:NoYesExtrasHospitalFund name:Member #:Concession CardAged or disability pension #:Exp date Date Format: DD slash MM slash YYYY Dept. Veterans Affairs card #:WhiteGoldExp date Date Format: DD slash MM slash YYYY Health Care Card #:Exp date Date Format: DD slash MM slash YYYY WorkCover (if applicable) Claim #:InsurerPrivacyDo you consent to communication being sent to your family doctor or GP?YesNoGeneral Practitioner's details (only complete this section if your GP was not your referring doctor)Name:Practice address:Are you happy for information to be given to your next of kin over the phone?YesNoNext of kin name:Contact numbers:Referral SourceHow did you hear about Dr David Sharp?GoogleReferred By DoctorWhite PagesPersonal recommendation:Other:Medical QuestionnaireMedical HistoryTo ensure optimal medical and surgical care, it is very important that you answer the following questions thoroughly and honestly please.Current Weight:Height:Have you ever experienced/undergone any of the following (tick whichever applies): Heart Attack Pacemaker Chest Pain Cardiac Stent Stroke DVT or Pulmonary Embolism TIA (mini stroke) Bypass Surgery Epllepsy Or Seizures DiabetesIf yes, is your diabetes controlled by: Diet Tablets Insulin Injections AsthmaIf yes, how is your Asthma managed?Have you ever been treated for, or diagnosed with (tick if applicable): Anxiety Depression PTSD Biopolar Body Dysmorphia Eating Disorder PsychosisAre you currently a smoker?NoYesIf yes, how many per day:If you have allergies to any creams. lotions. adhesives. seafood. latex, food or vitamins. please listMedicationsDo you take any blooding thinning medications, such as: Asprin Warfarin Plavix/ClopidogrelPlease list all medications you are taking. including over the counter, herbal or vitamin preparations:SurgeryHave you had any previous surgery?YesNoIf yes, please provide datails (surgical procedure, and approx date):PRIVACYPersonal and Health Information ConsentWe respect your rights to privacy and takes our privacy obligations seriously. We comply with the Australian Privacy Principles, found under the Privacy Act 1988(Cth). Our Privacy can be obtaned by requesting a copy at reception or on our website.We require your consent to collect personal information and health information about you. Please read this information carefully, and sign where indicated below.We collect information from you for the primary purpose of providing you with our healthcare services, We require you to provide us with your personal and health infoemation and your full medical history so that we may provide our services to you. We will also use the information you provide in the following ways:Apprpriately manage our practice, such as conduction audits and undertaking accreditation processes, manage billing and trainning staff.Effectively communicate with third parties,including Medicare Australia, private health insurers, govermment departments and other practitioners involved in your healthcare.During the post operative period, if you have any post operative complications, you may choose to send us questions or clinical photos foe your nurse and Dr Sharp to review. In signing this form and choosing to transmit images or questions to us via email or mobile phone post operatively, you acknowledge that these images may be transmitted to relevant clinicians via their devices (phones, ipad, email) for them to urgently review for post-surgical care as required.PHOTOGRAPHY CONSENTFor almost all patients, clinical photography will be taken to assist in your care. this ubcludes before amd after photos/videos in the clini, as well as intraoperative photos/videos during surgery. By signing this form, you provide permission for these images to become part of your confidential medical records.We also wold like to ask you for permission to ues these photos/videos for educational purposes in addition to their ues as part of your medical care. Names are not used and as far as possible, identifying factors are masked. these photos are extremely helpuful in teaching other doctors and helping other patients make an informed decision about their surgery, as you may have found yourself when resrarching your procedure. We are very grateful to those patients who permit us to share their images, and we are able to de-identify them if you wish-hoever you are under no obligation to agree to this.Do you consent to your before and after clinical photos being used:For the purpose of teaching other health professionals such as doctors, nurses and associated students?YesNoIn publications eg articles in medical journals?YesNoTo educate other patients in clinic and online?YesYes, but only de-identifiedNoImages will not be sold or trnsferred to any other entity for purposes that have not been agreed to.Declaration: I grant permission for photographs of me to be used in the formats indicated above. I am competent to execute this agreement.PATIENT SIGNATURE:Date Date Format: DD slash MM slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.
