Patient Non-Surgical Information Form

PATIENT INFORMATION FORM

PATIENT DETAILS

We adhere to the National Privacy Policy/Privacy Act 1998 Patient information collected by this clinic is used to assist in providing quality care and all information is treated confidentially. Some information may need to be communicated between the clinic and other professionals/ suppliers in order to facilitate your care. Thank you for your assistance.

Please answer all questions. If the question is not relevant, please write N/A for Not Applicable.

First and Middle Name *

Last Name *

Preferred Name

Date of Birth (dd/mm/yyyy) *

Gender

MaleFemaleOther

Marital Status

Occupation:

Country of Birth?

Religion:

Are you of Aboriginal or Torres Strait Islander origin?

YesNo

Do you require an Interpreter?

YesNo

If yes, please specify:

PATIENT CONTACT DETAILS

Home Phone

Mobile Phone *

Work Phone

Email *

Address *

Postcode *

City / Suburb *

State *

REFERRING DOCTOR

Referring Doctor’s Name

Referring Doctor's Name of Clinic:

Phone Number:

Address

MEDICARE

If you use an Alias please write the Alias name & surname

Medicare First Name

Medicare Surname

Medicare Card No. *

Reference Number: *

Expiry Date: *

Please tick if Medicare has your bank details registered for rebates from medical related consultations and procedures

PRIVATE HEALTH INSURANCE

Provider

Membership No.

Hospital Cover *

Hospital CoverExtra OnlyUninsuredUnsure

DVA Card

DVA No.

GUARDIAN DETAILS

Is the patient under 18 years old? If yes, please fill guardian's details.

YesNo

Guardian Full Name

Guardian Relationship

Guardian Phone Number

Guardian Email Address

EMERGENCY CONTACT DETAILS

Name

Mobile Phone

Email

Home Phone

Date of Birth:

NEXT OF KIN CONTACT DETAILS

Is the next of Kin same as your emergency (if yes, you do not need to fill this section)

YesNo

Next of Kin - Name

Next of kin - Email

Next of kin Home Phone

Next of kin - Mobile Phone

Best way to contact your next of Kin

Home PhMobile PhWork Ph

MEDICAL HISTORY

ALLERGIES *

YesNo

List ALL allergies to any medication, food, surgical tapes and dressings, oils/creams, etc)

Current Height (cm):

Current Weight (kg):

Current BMI:

Please list any other Medical History:

What concerns and body region/s would you like to discuss and when would you like the procedure/treatment?

List any medications including Retin A, roaccutane, hormone replacement or supplements taken:

List operations or previous physical trauma in the past:

List most recent waxing/threading/tanning/wind burn or fake tan:

List any family history of illnesses or diseases:

List Glycolic/AHA or other home care products used and any reactions:

List fillers, Botox, microdermabrasion, IPL, facial peel, facial waxing, electrolysis or depilatories had in past week and any reactions:

List any current/previous smoking or consumption of alcohol (or other drugs of addiction) per day:

List vigorous sports or aerobic activity and frequency:

*List other skincare:

MARKETING

*Please list details

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Do not send info to My Health Record

SIGNATURE

By submitting this form, I, the patient, understand that the information supplied by me is correct to the best of my knowledge and that I have read the Privacy Policy Statement. The information collected by the clinic is to provide me with quality care and will be treated with confidentiality in the provision of that care. This clinic uses Heidi AI Scribe to transcribe between doctors and patients for their clinical record. This is to provide comprehensive notes for the medical file. Heidi AI can also be used to translate for non-English speaking patients. No audio recording occurs, and Heidi AI is used purely as a transcribing and translating service. I understand that some operations or conditions require photographic records to be taken and recorded within my clinical file. By submitting this information and attending my consultation, I consent to the collection of clinical data, Heidi AI transcription and photography being recorded for my clinical file. Photographs and clinical records will be stored in accordance with the Privacy Policy and medical legislation. I consent to being contacted via phone, SMS or email by the practice.

I confirm that above information I have provided is true, complete and accurate. *

First and Middle Name: *

Last Name: *

Patient/ Guardian Signature *

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Today's Date *

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