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Consultation Details

Clinic Location*

Specialist*

Consultation Time

Hours

Minutes

AM/PM

Consultation Date

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Reason for visit*

Patient Details

Name*

Title First Last

Date of Birth*

DD slash MM slash YYYY

Sex*

Male

Female

Other

Address*

Street Address City State Postcode Country

Phone*

Mobile*

Email*

I agree to be contacted via phone and email*

Yes

Preferred Contact Method

Mailing Address

If different from above.

Address

Street Address City State Postcode Country

Next of Kin

Full Name

Relationship to you

Phone

Mobile

Medical Information

Medicare Number

Card Reference No

Expiry Date

DD slash MM slash YYYY

Do you have Private Health Insurance?

Yes

Health Fund Name

Are you covered for Bariatric Surgery (Item numbers 31572, 31575 & 31584)?

Yes

Don't know

Membership Number

Date Joined

DD slash MM slash YYYY

Aged / Disability Pension

Do you have a Veterans' Affairs Card?

Yes

Card number

Do you have Aged pension?

Yes

Pension number

Do you have Disability pension?

Yes

Pension number

General Practitioner

Full Name

Phone

Address

Street Address City State Postcode Country

Finance

Person Financially Responsible

If other, please specify

Work Cover (if relevant)

Employer

Phone

Address

Street Address City State Postcode Country

Insurance Company

Claims Number

TAC (if relevent)

Date of Accident

DD slash MM slash YYYY

Claims Number

Medical History

Do you have or have you ever had any of the following?
Please respond to every question

Heart disease, heart attack or chest pain

Yes

Heart murmur, palpitations or irregular pulse

Yes

Rheumatic fever

Yes

Anaemia or blood disorders

Yes

Blood clots in the legs or pulmonary emboli

Yes

CVA/Stroke/TIA

Yes

Seizures/Fits, faints or blackouts

Yes

Bleeding problems or bruising

Yes

Hepatitis

Yes

Asthma

Yes

Diabetes

Yes

Reflux, hiatus hernia or ulcers

Yes

Thyroid disease

Yes

Kidney disease

Yes

High blood pressure

Yes

Cancer

Yes

Snoring, sleep apnoea or CPAP

Yes

Anxiety/Depression

Yes

Sexual dysfunction

Yes

Do you have family history of any of the above?

Yes

Do you have family history of any of these listed medical conditions?

Please specify

Surgical History

Please list ANY previous surgeries with approximate dates, and advise of any complications

Allergies

Please list ANY allergies you may have to medications, tapes, dressings, anaesthetics, lotions or foods

Current Medications:

Please list current medications including dosage (prescription & non-prescription)

Are you taking any of the following?

Warfin

Plavix/Clopidogrel

Aspirin

Prednisolone

None of the above

Are you using any recreational drugs?

I smoke ____ cigarettes per day

I stopped smoking ____ years ago

How much alcohol do you drink?

How did you find out about LapSurgery Australia?

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In the event any of the details on this form change, I acknowledge that I will
advise LapSurgery Australia so that my records are up to date. Privacy Policy

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I consent to receive correspondence via email when necessary

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Consultation Details

Patient Details

Mailing Address

Next of Kin

Medical Information

Aged / Disability Pension

General Practitioner

Finance

Work Cover (if relevant)

TAC (if relevent)

Medical History

Surgical History

Allergies

Current Medications:

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