Confidential Patient Information Welcome to our 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. If you have any queries, please speak to one of our team members or Dr Sharp.Personal DetailsMsMissMrsMrMasterDrProfOtherDate Of Birth: Date Format: DD slash MM slash YYYY Given Name:Surname:Address:HomeWork:Mobile:Email: Please select:RetiredUnemployedEmployedOccupation: Claim 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 #:Insurer: PrivacyDo 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 History To ensure optimal medical and surgical care, it is very important that you answer the following questions thoroughly and honestly.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 Diabetes If yes, is your diabetes controlled by: Diet Tablets Insulin Injections Asthma If 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 Psychosis Are 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 list: MedicationsDo you take any blood thinning medications, such as: Asprin Warfarin Plavix/Clopidogrel Please 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 Consent We respect your right to privacy and take our privacy obligations seriously. We comply with the Australian Privacy Principles, found under the Privacy Act 1988 (Cth). Our Privacy Policy can be obtained by requesting a copy from reception or from 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 information 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: To appropriately manage our practice, including undergoing conduction audits and accreditation processes, managing billing and training staff. To effectively communicate with third parties, including Medicare Australia, private health insurers, government 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 for 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 CONSENT For almost all patients, clinical photography will be taken to assist in your care. This includes before and after photos/videos in the clinic, 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 would like to ask you for permission to use these photos/videos for educational purposes in addition to their use as part of your medical care. Names are not used and as far as possible, identifying factors are masked. These photos are extremely helpful in teaching other doctors and helping other patients make an informed decision about their surgery, as you may have found yourself when researching 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 - however, 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 transferred 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 represent that I am at least 18 years of age, I have read and understood the foregoing statement, and 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.
