Download Dr John Cosson - Oral and Maxillofacial Surgeon

Patient Information Form
TITLE: Miss / Mrs / Ms / Mr / Other __________________
SURNAME:
GIVEN NAMES:
Date of Birth:
Sex: M / F
ADDRESS:
________________________________________________Postcode___________
PHONE: (h)_________________(w)_________________(mobile)______________
EMAIL Address: _____________________________________________________
Medicare Card Number: __ __ __ __ __ __ __ __ __ __
No: next to name: __________
Expiry: __ __/__ __
Department of Veterans Affairs File No: ____________________
Health Fund: ________________________ Member No:____________________
Next of Kin:
Phone:
Contact Address
MEDICAL HISTORY
Current Medications:
Allergies:
Do you take aspirin or blood thinner regularly? Y / N ______________________
Are you pregnant? Y / N
Are you a smoker? Y / N
Have you ever had any of the following:
Heart conditions Y / N
Bleeding disorders Y / N
Joint replacement Y / N
Hepatitis/HIV/Aids Y / N
Cancer treatment Y / N
Rheumatic Fever Y / N
Other conditions that may be relevant: __________________________________
PAYMENT:
To reduce the cost of rendering accounts, it is requested that all consultations fees are paid on the day of
consultation. All surgical fees should be paid prior to surgery, otherwise accounting fees may be charged.
The information provided above is correct to the best of my knowledge, and I understand conditions of
payment.
SIGNATURE:
DATE:
P.T.O
Patient Information Form
CONSENT TO COLLECT PATIENT’S INFORMATION
Recent changes to the Privacy Laws now mean that a person’s written consent is required for
a health professional to obtain medical information concerning that person, and to
communicate medical information about that person with another health practitioner.
In view of this, the following form will need to be signed if you are happy for Dr John Cosson
to obtain such information and to liaise with other health practitioners concerning your
condition.
I,(name)…………………………………………………D.O.B……………………..
Address:………………………………………………………………………………
…………………………………………………………………………………………
give permission for Dr John Cosson
1)
To obtain medical information, details of previous consultation and results of
investigations performed from other medical practitioners, hospitals and health
care providers that pertain to my medical condition.
2)
To communicate with the referring medical practitioner concerning my medical
condition.
3)
To communicate with other health professionals directly involved with my medical
condition.
Please note: Any OPG’s (xrays) or Scans which are left at the premises of Coastal Oral and
Facial Surgery that have not been collected within 12mths will be disposed of.
Signature……………………………………………………………………………….
Date ……………………………………………………………………………………
Name (Parent/Guardian if Patient if under 18yrs): ………………………………………