New Patients

To save you time, you can fill in some of our required paperwork prior to your consultation. Either print out our forms and bring them in with you, or email them to us online using our secure email form.

Download Patient Details Form

Patient Details Form

Fax your completed forms to us at: 07 4041 2001 or bring them in with you for your consultation.

Send Your Patient Details Online

Your details are submitted to our server over a encrypted connection, which then sends an email to our staff. Once your details are entered into your secure file this email is deleted immediately. By submitting this form, you are agreeing to our Privacy Policy.

Treating Surgeon

Title

Date of Birth

Surname

Given Name

Preferred Name

Home Phone

Work Phone

Mobile

Would you like to receive an Appointment Confirmation Reminder via Text message?

Yes

Residential address

Suburb

Postcode

Postal address

Suburb

Postcode

Email Address

Name of Referring Doctor

Usual GP

Medicare Care Number: (10 digits)

Expiry

Do you have Private Health Insurance?

Yes

Name of Fund

Membership Number

Veterans Affairs Gold Card Numbers: Gold

White

Next of Kin (s)

Relationship

Contact no

Authorised Contact

Insurance/Compensation Claim

Claim No

Case Manager

Are you a diabetic?

Yes

If Yes, what type?

Diet

Tablets

Insulin

Are you a smoker?

Yes

If Yes, how many per day?

If Yes, are you aware that smoking has serious adverse effects on skin and bone healing?

Yes

Are you taking any medications? (please include any vitamins or homeopathic supplements)

Yes

If Yes, please list

Do you have any allergies?

Yes

If Yes, please list

Have you had any problems with anaesthetic?

Yes

Have you had any of the following in the last 12 months?

Heart Attack or Stroke

Had a Stent or Pacemaker inserted

Have you ever had a blood clot (DVT/PE)

Yes

Do you suffer from Arthritis?

Yes

Do you have Vascular Disease?

Yes

Do you live alone?

Yes

If yes, do you have someone close to you that can help you recuperate?

Yes

Do you have stairs at home?

Yes

At work are you mainly

Can you modify your work after surgery

Yes

Do you realise that excess weight significantly increases your risk of complications?

Yes