Patient Registration | Sunshine Coast Orthopaedic Group

Patient details

Name*

First Last

Sex*

Date of birth*

Postal Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Phone*

Mobile*

Email*

Occupation*

Next of kin / relationship*

Next of kin contact number*

Referring doctor*

Usual GP*

Medicare number*

Medicare reference number*

Medicare expiry*

Private health fund

Private health fund membership number

Workcover claim number

Workcover case manager

DVA number

DVA colour

Aged pension card number

Aged pension card expiry

Person responsible for account

Patient history

Reason for presentation*

Allergies*

Please list all medications and dosages*

Please tick if you are taking any of the follow medications*

Previous surgical procedures

Procedure

Year

Please tick if you consume the following:

Alcohol

Cigarettes

Other drugs

Do you participate in regular sports / exercise

Please tick if you have any of the following

Pacemaker

Cardiac Stents

Severe anaesthetic reactions

Blood Vessel Disease

History of Blood Clots (DVT/PE)

Privacy Policy

As a health care provider in the private sector, the Sunshine Coast Orthopaedic Group is bound by the National Privacy Principals provided in the Privacy Act 1988. These govern how we collect, handle, use, distribute and store personal information collected from our patients at the clinic. Ordinarily we do not release the contents of your file without consent. When dealing with other health care professionals, in order to obtain accurate diagnosis or treatment options we will ask your full consent to disclose personal medical details. Please indicate below and sign your consent for details to be disclosed when necessary.

Give permission for details relating directly to my medical condition to be discussed, if necessary, with other health care professionals.*

I do

I do not

NOTICE: Your actual signature to confirm the information provided in this form will be requested in person when you visit us.

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ONLINE PATIENT REGISTRATION FORM

Sunshine Coast University Private Hospital

Patient details

Patient history

Privacy Policy

SURGICAL OPTIONS

NON SURICAL

CUSTOMER SERVICES