Patient Information Patient Information Form Download Form Doctor Referred to Dr Dayan de FontgallandDr Tiong Cheng SiaDr Janina KaczmarczykDr Maneesha DedigamaDr Eu Ling NeoDr John ChenDr John ThomsonDr Chris LiyanageDr Eu Nice NeoDr Reizal Mohd RosliDr Gui Quan SayPATIENT DETAILSTitle First Name Last Name Middle Name Preferred Name Maiden Name DOB (dd/mm/yyyy) Gender Occupation Mobile Phone Do not SMS Home Phone Email Do not Email Work Phone Residential Address Post Code Postal Address (if different to Residential) Post Code Is English your first language? YesNoDo you require an interpreter? YesNoPlease Specify EMERGENCY CONTACT / NEXT OF KIN:First Name Last Name Mobile Phone Relationship Are you happy for information to be given to your next of kin over the phone? YesNoMEDICARE & PRIVATE HEALTH INSURANCE DETAILS:Medicare Number: Ref: Do you have Private Health Insurance (Hospital cover) YesNoHealth Fund Member Number Date Joined Do you have a DVA card? YesNoCard Type GoldWhiteDVA No Do you have a Concession card YesNoHealth Care No Expiry Date (dd/mm/yyyy) Pensioner Concession No Expiry Date (dd/mm/yyyy) Is this a Work Cover Claim? YesNoInsurance Company Claim ID Claim Manager Phone Email DOCTOR INFORMATION:GP Name & Address: Referring Doctor Name Practice Phone Address Please tick if you do not want any correspondence to be sent to your referring doctor and/or G.P I do not want any correspondence to be sent to your referring doctor and/or G.PMEDICAL HISTORY:To ensure optimal medical and surgical care it is important that you answer the following questions.Height (cm) Weight (kg) Do you have any previous illness or current medical condition we need to be aware of (tick below)? AsthmaAnginaBleeding ProblemsCancerDeep vein thrombosisDiabetesHeart DiseaseHepatitisStrokeHigh CholesterolSleep ApnoeaHigh Blood PressureOtherIf other provide details Do you have any allergies or sensitivities? YesNoIf yes please specify Have you ever been told you have any hospital acquired infections? ESBLVREMRSAPseudomonasAre you taking blood thinning medication? YesNoIf yes please specify Are you currently taking any weight loss medication? YesNoIf yes please specify Are you taking any other medication? YesNoIf yes please specify PATIENT CONSENTUse of Technology and AI Tools in Documentation I acknowledge and consent to the use of AI tools to assist in recording and preparing clinical documentation during my consultations.Our clinic uses secure AI-powered tools to assist in recording consultations and preparing medical documentation such as progress notes, referral letters, and correspondence to GPs. These tools are used by our specialists to improve the accuracy and efficiency of your care. Your information is handled securely, in line with our Privacy Policy and Australian privacy laws.Privacy Policy *I have read and understood the Privacy PolicyMedicare and Health Fund Billing *I authorise the practice to process Medicare and/or private health fund claims on my behalf for services rendered. I understand that I am responsible for any out-of-pocket expenses or surgeon gap fees not covered by Medicare or my health fund.Signature (patient or guardian) * Date (dd/mm/yyyy) *PhoneSubmit
