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),

Dr Sahil Vohra (Medical Specialist Physician) & Kimberley Parsons (Registered Nurse).

Please complete this online form and if you have any technical difficulties, please contact us via admin@lowerhuntermedical or call 02 49112 336.

Title

First Name *

Middle Name *

Last Name *

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 *

General Practitioner's Name, Address and Telephone *

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. *

DVA

Injury covered

DVA number

Type of cover

WhiteGold

Name of your private health fund

Health fund number

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

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.

If you have a copy of any discharge summaries 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: *

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 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

If you have any past reports, please upload

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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.

What is your height? *

What is your weight? *

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 *

Please use the following to upload any reports, images, results or documentation.

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If you have any technical difficulties, the form is saved and we can access it for you and resend you the link of your work submitted so far, so please call 02 49 112 336 admin@lowerhuntermedical.com.au

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