Gold Coast Orthopaedic Specialists Your Practice Online
Gold Coast Orthopaedic Surgeon
Patient Info

Please complete this form before your consultation

Fields marked (*) are compulsory

Given Names*
Preferred Name
If Child: Parent /Guardian Full Name
Postal Address
(If different to above)
Date of Birth*
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
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.
Knee Surgery
Hip Surgery
Shoulder Surgery
Gold Coast Orthopaedics
Gold Coast Orthopaedic Surgeons, Benowa QLD
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