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Menu
Home
Procedures
Breast
Breast Augmentation
Breast Lift
Breast Reduction
Breast Asymmetry Correction
Breast Reconstruction
Breast Revision
Inverted Nipple Correction
Tuberous Breast Correction
Male Breast Reduction
Safer Breast Lift Surgery
Body
Tummy Tuck Abdominoplasty & Mummy Makeovers
Arm Lift
Brazilian Butt Lift
Labiaplasty
Liposuction
Body Lifts
Surgery after Weight Loss
Face
Brow Lift & Eyelid Surgery (Blepharoplasty)
Facelift
Otoplasty – Ear Surgery
Non-Surgical
Lip Enhancement
Treatment of Lines and Wrinkles
Excessive Sweat Management
Migraine Management
Skin Peels
Complimentary Skin Assessment
Cosmetic Advisory Service
Skin Care Products
General
Scar Revision Gold Coast & Toowoomba
Skin Cancer Surgery
Gallery
GC Non-Surgical Symposium
Accolades
News
Bookings
For Patients
Patient Registration
Implant Removal – Pre Explant
Implant Removal – Post Explant
Breast Implant Removal Webinars
Contact Us
Patient Registration
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Patient Registration
New Patient Details
Title
*
Full Name
*
DOB
*
DD slash MM slash YYYY
Preferred Name
Occupation
Address
Phone
Home
*
Work
*
Mobile
*
Email address
Are you happy to receive Emails?
*
Are you happy to receive Emails?
Next of Kin
Relationship to Patient
NOK Phone:
Referring Doctor
Usual G.P
Medicare
Medicare No
Ref No (#. to left of name)
Exp. Date
DD slash MM slash YYYY
Veterans Affairs
Type
DVA White
DVA Gold Card
File Number
Aged Pensioner
Pension No
Expiry Date
DD slash MM slash YYYY
Private Health Insurance
Fund
Membership Number
How did you hear about our practice?
How did you hear about our practice?
GP Referral
Former patient
Print advertisement
Internet (Website)
Radio
Word of Mouth
Television
Other
Other
MEDICAL HISTORY: Have you had any of the following? (Please circle)
Rheumatic Fever
*
Yes
No
Asthma
*
Yes
No
Heart Ailment
*
Yes
No
High Blood Pressure
*
Yes
No
Epilepsy / Fit
*
Yes
No
H.I.V.
*
Yes
No
Kidney Disease
*
Yes
No
Reflux Disease
*
Yes
No
Heart Attack
*
Yes
No
Stroke (CVA)
*
Yes
No
Thrombosis / Blood Clots
*
Yes
No
Hepatitis A
*
Yes
No
Hepatitis B
*
Yes
No
Hepatitis C
*
Yes
No
Diabetes
*
Yes
No
Type 1 Insulin
Yes
No
Type 2 Oral Only
Yes
No
Diet Only
Yes
No
Medical History
Please list any medical problems not listed above
Surgical History
Please list any previous surgical procedures & year of surgery
Previous General Anaesthetics
Have you or any of your family had any problems with anaesthetic in the past?
*
Yes
No
If yes, please explain here
Medications
Please list current medications
Are you on medications to thin the blood such as
Are you on medications to thin the blood such as
Warfarin/Marevan
Plavix
Iscover
Asasantin
Persantin
Aspirin
Allergies
Are you allergic to or have had an adverse reaction to anything at all
Do you have any health problems or family history which has not been mentioned?
Do you have any health problems or family history which has not been mentioned?
*
Yes
No
If yes, please explain here
Do you smoke?
Do you smoke?
*
Yes
No
Alcohol
Alcohol
*
Yes
No
Height
Weight
Signature of Patient/Guardian
*
Witness
*
Privacy Agreement
I acknowledge that the collection of information pertaining to my health care in this practice is managed under strict guidelines governed by the Pricate Sector Privacy Amendment Act enacted on the 21st December 2001. I consent to the sharing of this information as is required to facilitate this health care.
I acknowledge that the collection of information pertaining to my health care in this practice is managed under strict guidelines governed by the Pricate Sector Privacy Amendment Act enacted on the 21st December 2001. I consent to the sharing of this information as is required to facilitate this health care.
