New Patient FormsHome > New patient formsCONFIDENTIAL PATIENT INFORMATIONWelcome 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 Details Ms Miss Mrs Mr Master Dr Prof OtherDate Of Birth: DD slash MM slash YYYY Given Name:Surname:Address* Street Address City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country HomeWork:Mobile:Email: Please select: Retired Unemployed EmployedOccupation:Claim DetailsMedicare number:Ref #:I consent to be bulk billed, where applicable* I consent to be bulk billed, where applicable*Do you have Private Health Insurance? Please select: No Yes Extras HospitalFund name:Member #:It is important that we have accurate private health insurance information, as it may impact your quote:What is your level of hospital cover (basic, bronze, silver, gold – please also specify ‘plus’ cover)*Have you served the 12-month waiting period for this level of cover?* Yes NoConcession CardAged or disability pension #:Exp date: DD slash MM slash YYYY Dept. Veterans Affairs card #: White GoldExp date: DD slash MM slash YYYY Health Care Card #:Exp date: DD slash MM slash YYYY WorkCover (if applicable) Claim #:Insurer:PrivacyDo you consent to communication being sent to your family doctor or GP? Yes NoGeneral 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? Yes NoNext of kin name:Contact numbers:Referral SourceHow did you hear about Dr David Sharp? Google Referred By Doctor White 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.To calculate your BMI please click here: https://www.heartfoundation.org.au/bmi-calculatorCurrent Weight:Height:BMI: (Does not apply for skin lesion surgery)BMI: Dr Sharp does not operate on patients who have a BMI over 30, due to the increased risk of post op complications.Please get in touch to cancel or postpone your appointment if this applies to you.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? No YesIf 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/ClopidogrelPlease list all medications you are taking, including over the counter, herbal or vitamin preparations:SurgeryHave you had any previous surgery? Yes NoIf yes, please provide datails (surgical procedure, and approx date):PRIVACYPersonal and Health Information ConsentWe 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 CONSENTClinical photos may be taken at your consultation and will form part of your clinical record. Images will be accessible to our staff for clinical purposes. Photos are stored in a secure server, compliant with the Australian Privacy Principals.PATIENT SIGNATURE:Date: DD slash MM slash YYYY Please tick to acknowledge that we contact our patients via email and SMS to confirm appointments, send booking information and patient education content. Please note that most email and SMS services are not encrypted, and therefore not protected from interception or hacking. If you do not consent to us contacting you via email or SMS, please contact our clinic directly by calling 3202 4744 before completing your form, so we can establish alternative ways of contacting you.* Please tick to acknowledge that we contact our patients via email and SMS to confirm appointments, send booking information and patient education content. Please note that most email and SMS services are not encrypted, and therefore not protected from interception or hacking. If you do not consent to us contacting you via email or SMS, please contact our clinic directly by calling 3202 4744 before completing your form, so we can establish alternative ways of contacting you.*
