Test Form : Wickham Terrace Surgical Centre

Test Patient

Patient Details

Title*

First Name/s*

Last Name*

D.O.B.*

Month*

Year*

Preferred Name

Occupation*

What is your weight in kgs?*

What is your height in cms?*

Street Address*

City/Suburb/Town*

State*

Mobile Phone*

Alternative Phone

Leave Voice Mail?*

Do you have an email address*

Your Email Address*

I consent to the use of my email by WTSC for the exchange of health information and acknowledge that while all due care and best practice will be observed, email by nature is not a secure form of communication*

Next of Kin

First Name*

Surname

Phone

Relationship

Your GP Details

Doctor\'s Name*

Practice Name

Phone

Street Address

City/Suburb/Town

State

----------------------------------------------------

Test Legal

Legal Details

Is the patient 18 years of age or over?*

Guardian Details

Name*

Phone Contact*

Email Address*

Street Address*

City/Suburb/Town*

State*

Do You wish have an Emergency Contact?*

Title*

Name*

Phone Contact*

Relationship*

Are there any custody agreements or court orders in place?*

YesNo

Please give details

Who referred you to this Practice?*

Doctor Details

Doctor's Name*

Practice Name

Phone

Street Address

City/Suburb/Town

State

Dentist Details

Dentist's Name*

Practice Name

Phone

Street Address

City/Suburb/Town

State

Where did you hear of us?

Information disclosure*

Do you wish to authorise a person to take messages regarding a reminder/change of appointment/clinical details relating to your healthcare (if you do not nominate anyone, we will only be able to speak with you regarding the above)

Title*

Name*

Phone Contact*

Relationship*

----------------------------------------------------

Test Billing

Billing Details

Do You hold a Medicare Card?*

Expiry Date (DD/MM/YYYY)*

Medicare Number*

Ref #*

*Note: The reference number is on the far LEFT of each name on the card

Is this a work cover claim?*

Do You hold a DVA Card?*

Expiry Date (DD/MM/YYYY)*

Reference Number*

Colour*

Do You have Health Insurance?*

Name of health fund* Commencement Date (DD/MM/YYYY)* Membership Number* Does your insurance cover hospital? Does your insurance cover dental? Have you held this level of cover for 12 months or more? Are there any excesses, restrictions or exclusions on this policy?*

Please List
NOTE: This information is needed at your consultation and can be obtained in advance from your health fund

----------------------------------------------------

Test Disclaimer

Privacy

Thank you for supplying this information as it will help us treat you as safely and efficiently as possible.

It is necessary for us to collect and pass on information from patients and sometimes others associated with your care in order to attend to your health needs, and for associated administrative purposes.

De-identified medical records (including photographs) are used by this practice for purposes of education, patient management, and research. Please advise the staff if you do not agree to this.

You have access to any personal information of yours that we hold, and the right to know how that information is used.

Please ask us if you would like a copy of our Privacy Policy or if you have any concerns regarding this process.

----------------------------------------------------

Notice: Please be advised that for your safety, CCTV surveillance is in use throughout our practice. Recordings are for security purposes only and handled in compliance with privacy laws.

----------------------------------------------------

Payments

Payments for consultations are required on the day.

Unless otherwise arranged, payments for surgery in hospital are to be made within 10 days.

Claims to Medicare and/or health Funds are to be submitted after payment is receipted.

Please indicate if you have assigned POWER OF ATTORNEY ?*

Please indicate if you have an ADVANCED HEALTH DIRECTIVE ?*

By completing this form I, the undersigned, declare that*

Accept responsibility for the information provided above and agreement to the treatment plan.*

I accept responsibility for payment of all accounts. Payments for consultations are required on the day. Unless otherwise arranged, payments for surgery in hospital are to be made within 10 days and claims to Medicare and/or health Funds are to be submitted after payment is receipted. *

Understand that payments not made on time may be subject to collection charges*

COVID19

Are you fully vaccinated for COVID ?

Have you had COVID previously

Approx Date of Onset, Still current?, Treating Doctor

NOTE:

If you do not receive confirmation after you click SUBMIT below, you will be asked to go back and enter any missing information and retry; if still unsuccessful after that, please contact us on 0738394717 or office@wtsc.com.au

Test Medical

Medical Information and History

To fully optimise your care, we require your complete medical history.

Have you or do you have ANY medical conditions*

Type of Illness, Approx Date of Onset, Still current?, Treating Doctor

Have you ever had any operation or surgical procedure?*

Operation, Approximate Date, Any Complications?, Treating Doctor

Are you taking ANY medications?* (It is important you include any antibiotics, pain killers (eg any brands of ibuprofen or aspirin or other anti-inflammatory) blood thinners, vitamins, herbal or food supplements, bone strengthening or weight loss/diabetic medications, as well as injectables and weekly, monthly, 6monthly and yearly treatments.)

Medication Name, Strength , Time of day taken?

Have you or your relatives had any difficulty with a general anaesthetic?*

Please give details

Do you have any allergies to food or medications?*

Allergy, Details of Reaction

Do you smoke/vape or have previously smoked/vaped? If so how many/often?*

Please give details ?

Have you EVER had a general anaesthetic? *

Are you under treatment for psychological problems?*

For women, could you be pregnant?*

Have you undergone neurosurgery before 1988?*

Have you had radiation or chemotherapy*

Have you been treated prior to 1986 with pituitary hormone for growth or fertility?*

Have you received corneal grafts?*

Have you or any of your relatives suffered from CJD (Creutzfeldt-Jakob Disease) or other related diseases?*

Do you give consent to your doctor to access your My Health Record if needed?*

Do you accept the risk of a blood transfusion in the unlikely event it is unavoidable?*

----------------------------------------------------

Test All

cf7form shortcode key error, unable to find form, did you update your form key?