Patient Registration Form

Patient Registration Sheet

Privacy Note

This Practice will collect information about you and your health under the guidelines of the National Privacy Principles 2001. Your attendance, together with your signature on this form will be taken as consent for the collection of this information. It will be used in the course of managing your healthcare and will include referral to additional specialists and allied health carers. Any unauthorised access will not be allowed without your permission. At times it will be necessary to collect health information from family members. Should you have any concerns, questions or complaints about any issue relating to privacy of your personal information, please contact Dr Savvoulidis to discuss the matter.

Patient Information

Salutation

Surname

Given Name

Home Address

Post Code

Different Postal Address

Different Postal Address?

Postal Address

Post Code

Home Phone Number

Work Phone Number

Mobile Phone Number

Medicare Card Number

Your Reference Number

Expiry Date

Occupation

Concession Details

Do you have a Pension Card?

Pension Card Number

Expiry Date

Do you have a Health Care Card?

Health Care Card Number

Expiry Date

Do you have a Veteran Affairs Card?

What Type of Veteran Affairs Card?

Gold

White

What condition does the white card cover?

Cultural Details

Are you Aboriginal or Torres Strait Islander

Yes

Other background?

Private Health Details

Dr Savvoulidis is a preferred provider with all major health benefit providers except NIB and Mildura Health Fund. If you are with either of these health insurers, you will be charged an increased co-payment should you require surgery.

Do you have Private Hospital Insurance?

Yes

Private Health Fund name

Membership Number

Is your Membership current?

Yes

When will your private health commence?

Doctor and Family Details

Family Doctor

Address

Post Code

Referring Doctor

Address

Post Code

Next of Kin

Relationship

Home Phone Number

Work Phone Number

Mobile Phone Number

Other - Please Specify

Medical Information

It Is important that you answer all of the questions asked

Height

Weight

Are you sensitive or allergic to medicines, foods, tapes, metals, latex/rubber, antiseptics, other?

Yes

Which ones?

Do you suffer from asthma, cough, shortness of breath?

Yes

Do you suffer from diabetes

Yes

Diabetes Type

Do you suffer from sleep apnoea?

Yes

Do you use a CPAP machine?

Yes

Do you have any kind of heart condition?

Yes

Type of heart condition

Do you have a pacemaker?

Yes

Name of Cardiologist

Have you had gastric banding?

Yes

Have you had any other surgical weight loss procedure?

Yes

Do you suffer from arthritis?

Yes

Do you suffer from DVT/Blood clots

Yes

Do you suffer from hypertension?

Yes

Have you had any orthopaedic operations?

Yes

Please list operation and year of surgery.

Are you a smoker?

Yes

How many per day?

Do you drink alcohol?

Yes

How much per week?

Do you have or have you ever suffered from VRE (Vancomycin Resistant Enterococci)

Yes

Do you have or have you ever suffered from MRSA (Methicillin-resistant Staphylococcus Aureus)

Yes

Have you ever suffered from Hepatitis B or Hepatitis C?

Hepatitis B

Hepatitis C

Is it still active?

Do you take or have you recently taken Blood Thinning Medications. eg: Aspirin, Astrix, Cartia, Warfarin, Clopidogrel, Plavix, or Arthritis medication

Yes

Name(s) of medication

Are you taking any non prescription or natural complementary medications?

Yes

What medications?

Please list all medications you are taking along with their strengths

Your Account

Please note that this practice does not bulk bill. All payments for your consultation are to be made in full on the day of your visit. EFTPOS facilities are available. If you are to be booked for surgery you will be charged a Co-payment which is an extra cost. This is not Medicare rebateable and is not covered by your Private Hospital Insurance.

Your Declaration

I have read the above information and the Privacy Statement. I agree to pay all of my accounts on the day of each visit. I also understand that failure to pay my account could incur extra charges which are payable by myself.

I accept the said conditions (Please type your name to accept the conditions)

Your Full Name

Todays Date

Privacy Note

Patient Information

Concession Details

Cultural Details

Private Health Details

Doctor and Family Details

Medical Information

Your Account

Your Declaration

Our Locations

Rose Park Surgery

Westcare Specialist Centre

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Contact Details

Surgery Hours