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Gold Coast Orthopaedic Surgeon
 
Patient Info

Please complete this form before your consultation

Fields marked (*) are compulsory

Title*
Surname*
Given Names*
Preferred Name
If Child: Parent /Guardian Full Name
Address
Postcode
Postal Address
(If different to above)
Postcode
Date of Birth*
Occupation
Home Phone Work Phone
Mobile* Email*
Name of Referring Doctor*
Name of usual Gp (If different to above)
Medicare No
Ref No
Expiry Date mm/yyyy
Private Health Fund
Member No
Are you covered for Private Hospital ?
Yes No
Are you a veteran’s affairs patient ?
Yes No
Gold Card No
White Card No
Are you a workcover patient ?
Yes No
If so Claim Number
Medical History: Note current or past problems
Heart and Lung Systems
Digestive System
Urinary System
Deep Vein Thrombosis/ Pulmonary Embolus
Brain and Nervous System
Previous Hospitalisation or Surgery
Other
Are you taking Blood Thinning Medication
Yes No
Is there a List of your Current Medications on your referral: Yes No
Family History of medical problems: Nil

Allergies: give details: Nil

PRIVACY ACT DEC 2001 – Please read and accept consent

I consent to the consultation and examination requested and to Dr Angus Nicoll / Dr David Christie using the personal and health information collected in accordance with the Privacy Act. I authorize Dr Angus Nicoll / Dr David Christie to provide health information to my referring practitioner or any other medical practitioner that is relevant to my treatment.
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