About Mr Patten
Our Medical Team
Your First Visit
Request an Appointment
Partial Knee Replacement
Total Knee Replacement
Patient Registration Form
Medical History & Medications
Date of Birth
Medicare & Health Insurance
Reference Number (To the left of your name)
Private Health Insurance Fund
Veterans Affairs Card Number
Next of Kin Details
Relationship to you
Next of kin phone number
Usual GP (if different from referring GP)
Physiotherapist (if applicable)
I have been diagnosed with a heart condition, e.g. irregular rhythm, heart disease
I have a pacemaker and/or defibrillator
Type / brand
I have had a heart attack and/or have had surgery on my heart
Type of surgery you have had
I have a cardiologist
Do you suffer from Diabetes?
Yes, type 1
Yes, type 2
Is your diabetes controlled by?
Do you take any blood-thinning medications?
Have you ever had a bleeding or clotting problem?
Have you ever had a stroke or mini-stroke?
Please list all your current medications below, if all is not included on your doctor's referral
Do you have any allergies? (ie. medications, tapes, dressings, latex, etc)
We require your consent to collect personal information on your behalf. This medical practice collects information for the primary purpose of providing quality health care. We require that you provide us with your personal details and medical history so we may properly assess, diagnose and treat your health care needs.
We will use the information in the following ways:
- Administration purposes in running the practice.
- Billing purposes, including compliance with Medicare, WorkCover & TAC.
- Correspondence with others involved in your care, including your GP, treating doctors, physiotherapists and other specialists.
I understand that I am not obliged to provide any information requested but that failure to do so may compromise the quality of my treatment.
I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.
I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice of.
How did you hear about Mr Patten?
Royal Australian College of Surgeons website