Patient Information

Patient Registration ( Patient Information )

To help us provide you with the best possible care, please fill out our patient registration form.

This information will be kept in your file and treated as confidential (see Privacy Policy)

Step 1 of 4
Register Now

Your consultation date *
Please confirm your consultation date

Consultation Time *
Please enter the appointment time of your next booking.

Patient Details

Title *
Please select your title

First Name *
Your given name

Surname *
Please enter your surname

Sex *
Please select a gender

Age *
Please enter your age

Date of Birth *
Please enter your DOB

Address *
Please enter your address including house #,state, country and postcode

Suburb *
Please enter in your Suburb

State *
Please enter your State

Postcode *
Please enter your postcode

Phone *
Please enter your phone or mobile number

Mobile
Enter your mobile number

Email *
Please enter your email address.

Emergency Contact

Full Name *
Please fill in the full name of your emergency contact

Relationship to you
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Telephone *
Please enter a contact phone number

Mobile
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Next of Kin

Full Name
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Telephone
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Mobile
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Medical Information

Medicare Number *
Please enter your Medicare number

Card Ref. No.

 Number left of your name on your card
Please enter your Medicare card reference number

Medicare Expiry date *

  / 
MMYY

I have Private Health Insurance
Let us know if you have private health insurance

Health Fund Name
Please enter your health fund name

Membership Number
Please enter your health fund membership number

Date Joined
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Aged / Disability Pension

Do you have a Veteran Affairs Card?
Please select what type of Veterans Affairs card you have

Card Number
Please enter in your Veterans Affairs card number

Do you have Aged pension?
Please choose if you have Aged pension

Pension Number
Please enter you Aged pension number

Do you have Disability pension?
Please select if you have a Disability pension

Pension Number
Please enter in your Diability pension number

General Practitioner

Full Name

 If different from referring doctor
Please enter your GP's full name

Address
Please include your GP's full address inc. state and postcode

Telephone
Please enter in a valid telephone number

Finance

Person Financially Responsible *
Please specify who is financially responsible

If other, please specify
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Work Cover (if relevant)

Employer
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Telephone
Please enter in the phone number for your Workcover claims officer

Address
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Insurance Company
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Claims Number
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TAC (if relevant)

Date of Accident
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Claims Number
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Medical History
To help us provide you with the best possible care please answer the following questions. This information will be kept in your file and treated as confidential (see privacy policy)

Do you have or have you ever had any of the following?
Heart disease, heart attack or chest pain *
Please check yes or no
Heart murmur, palpitations or irregular pulse *
Please check yes or no
Rheumatic fever *
Please check yes or no
Anaemia or blood disorders *
Please check yes or no
Blood clots in the legs or pulmonary emboli *
Please check yes or no
CVA/Stroke *
Please check yes or no
Seizures/Fits, faints or blackouts *
Please check yes or no
Bleeding problems or bruising *
Please check yes or no
Hepatitis *
Please check yes or no
Asthma *
Please check yes or no
Diabetes *
Please check yes or no
Reflux, hiatus hernia or ulcers *
Please check yes or no
Thyroid disease *
Please check yes or no
Kidney disease *
Please check yes or no
High blood pressure *
Please check yes or no
Cancer *
Please check yes or no
Snoring, sleep apnoea or CPAP *
Please check yes or no
Anxiety/Depression *
Please check yes or no
Sexual dysfunction *
Please check yes or no
Are you/could you be pregnant? *
Please check yes or no

Do you have family history of any of the above (please list)
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Surgical History

Please list ANY previous surgeries with approximate dates and/or complications
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Allergies

Please list any allergies you may have to medications, tapes, dressings, anaesthetics, lotions or foods
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Current Medications

Please list current medications including dosage (prescription & non-prescription)
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Are you taking any of the following?*




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Are you using any recreational drugs? (please list)
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I smoke

 per day
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I stopped smoking

 years ago
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How much alcohol do you drink?

  per 
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How did you find out about LAPSurgery? *
Please let us know how you discovered LAPSurgery
Please confirm that your details are correct

How do I start the process?

contact us

Complete our simple
online enquiry form

1300 527 787

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About LSA

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