2023 Pre op New Patient Form

2024 SURGICAL SUPPORT SERVICES

NEW PATIENT FORM

Our preoperative assessment team includes

Dr. Sergio Diez Alvarez (Medical Specialist Physician) & Kimberley Parsons (Registered Nurse).

Please complete this online form at least one week before your appointment.

If you do not have access to a computer/ internet or smartphone- please have a family member support you.

If you experience any technical difficulties, please contact us 02 4911 2336.

Title

First Name *

Middle Name *

Last Name *

Please upload a photo - head shot like passport, for patient identification, safety and accreditation purposes. *

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If you are completing this form via your phone, iPad, or PC, simply upload a photo you have stored on your device.

Address

Marital status *

Date of Birth *

Gender Identity

Home Telephone

Mobile Telephone *

Consent to receive SMS? *

YesNo

Email Address *

Emergency Contact Name *

Emergency Contact Telephone *

Emergency Contact Relationship *

Next of Kin Name *

Next of Kin Telephone *

Next of Kin Relationship *

Do you consent to a partner/ friend or family member to attend consultations, access information and results and/or speak to medical and administrative staff on your behalf. If yes, you need to identify person or persons in the next question. *

Yes No

Please list partner/ friend or family member whom you give consent to attend consutations, access information and results, and/or speak to LHM medical and administrative staff on your behalf. Please provide their contact number. *

General Practitioner's Name, Address and Telephone *

Usual pharmacy's name, telephone and fax details.

Hospital In-Patient Information

Medicare Number (if applicable) *

Medicare Line Number *

Medicare Expiry Date

Medicare Agreement:
Where relevant, I (the patient) agree to the assignment of the Medicare benefit directly to the health professional for the preoperative consultation services provided. *

My Health Record is a safe and secure place to keep your key health information, available to you and your healthcare providers anytime, including in an emergency. To learn more please click on this link: Digitalhealth.gov.au

For example, My Health Record enables Dr. Diez Alvarez to review past pathology, imaging, GP summaries, and discharge summaries that have been uploaded to your My Health Record, this helps him gain more insight into your health and the best treatment and care management for you.

Do you consent to Lower Hunter Medical accessing your "My Health Record"? *

YesNo

Do you consent to Lower Hunter Medical uploading your consultation report to "My Health Record"? *

YesNo

If you have a My Health Record access code, please enter it here:

DVA

Injury covered

DVA number

Type of cover

WhiteGold

Name of your private health fund

Health fund number

Please select *

Australian - non-IndigenousIndigenousTorres Strait Islander

Other

Surgery details

Name of Surgeon *

Name of Anaesthetist (if known)

Medical Specialist Physician

Planned date of surgery *

Have you had previous surgery? *

YesNo

Please list any operations you have ever had. *

Have you or anyone in your family ever had any reactions/ side effects from anaesthetics? *

YesNo

Please select one: You have

Your own teethUpper dentures Lower denturesUpper and lower dentures

Have you ever had any of the following?

Deep vein thrombosis (DVT)Pulmonary embolism (PE)Staphylococcus aureus - golden staph (MRSA)

How far can you walk before you become short of breath or the pain is too great?

Do you use mobility aids?

Walking stickCrutch (es)Walkerwheel chair

Do you have internal and external stairs at home? If yes please list how many, if you have hand rails - for discharge purposes.

Do you have a history of falls, if so please list any issues or causes.

If you have a copy of any discharge summaries over the past 12 months, please upload.

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Medical History

Medications *

Supplements - Please list any current herbal or nutritional supplements being taken. Please list dosage and reason for taking these. *

Allergies /Intolerances: *

Do you have any dietary requirements?

Are you aware of having any problems with your lungs (breathing)? (such as Asthma, PE, TB, COPD, chronic bronchitis)

Do you have any issues or problems with your heart, blood pressure or chest pain? (such as hypertension (high Blood pressure BP), hypotension (low BP), anaemia, AF, coronary artery disease, peripheral vascular disease etc...)

What is your normal blood pressure and heart rate (pulse) reading *

Are you aware of any issues with your health at all? examples may include: GORD, Gout, kidney problems, bowel issues, any chronic conditions? *

Do you see any specialists for anything?Please provide name and phone number

What is your height? *

What is your weight? *

Please select one

Current smokerEx-smokerNon-smoker

If you are a current or ex- smoker, please list how many years you smoked, how much and if you have given up- when.

Do you consume alcohol? *

YesNo

If you consume alcohol, please advise how many alcoholic beverages you (on average) have daily.

Consent

I declare that the information I have provided is true and correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or the patient's) health. I undertake to inform the doctor(s) of any changes in medical status.

I consent to the sharing of my (or the patient's) clinical information when necessary for treatment or care by other professionals, or as required by law.

I consent to the preoperative assessment report by Dr. Sergio Diez Alvarez to be provided to the Surgeon, Anaethetist, my GP, and the Hospital in preparation for my upcoming surgery.

I give my consent for Lower Hunter Medical to access any of my medical information, reports, and results from investigations and examinations, from any source for my assessment and management.

I confirm that I am responsible for the payment of consultation and treatment fees, including cancellation fees if they are incurred. (Please note that 24 hours notice is required for appointment cancellations or cancellation fees may be charged).

Signature *

Draw signature|Type signatureClear

Date *

As Dr. Diez Alvarez is an Internal Medicine Specialist, he reviews all body systems in the context of your symptoms and medications, the more information you provide the better he is able to support you. Please use the following to upload any reports for other specialists (such as Cardiologist/ Neurologist etc..), images (X-Rays/ CT/ MRI), results (pathology, studies (such as sleep study, lung function tests etc..) or any other health documentation. Thank you.

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Once you press submit, you will receive an instant confirmation of successful submission and you will also receive an email confirmation.

If the form does not instantly state "successfully submitted", please scroll up and any questions not completed will be highlighted in red, these will need to be completed before submission is successful.

If you have any technical difficulties, the form is usually autosaved at various intervals and we can access it for you. If the form is no longer accessible to you, we can resend you the link to your work submitted so far.

Please do not hesitate to call us at any time on 02 49 112 336

Thank you

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