Patient Registration Form for Dr Tim Manzie

PATIENT DETAILS

First Name *

Middle Name

Last Name *

Date of Birth *

ATSI

AboriginalTorres Strait IslanderPrefer not to say

Gender

MaleFemalePrefer not to say

PATIENT CONTACT DETAILS

Residential Address *

Postcode *

City / Suburb *

State *

Postal Address

Postcode

Suburb

State

Home Phone

Mobile Phone *

Work Phone

Email *

PARENT DETAILS

First Name:

Surname Name:

Medicare Card Number:

Medicare Ref:

EMERGENCY CONTACT / NEXT OF KIN

Name *

Mobile Phone *

Email

ASSOCIATED DOCTORS

Referring Doctor’s Name *

Practice Location *

Phone *

Email

General Practitioner - (if different to above)

GP - Practice Location

Dentist

Dentist - Practice Location

Do you see any medical or dental specialists?

Name

Specialty

Location

Name

Specialty

Location

Name

Specialty

Location

Other medical or dental specialists:

FINANCIAL INFORMATION

I am a current defence force member and have been referred from a defence force medical service *

YesNo

Medicare Card No. *

Medicare Ref (Position on Card) *

Expiry *

Private Health Fund

Membership No.

Expiry

My private health covers:

HospitalHospital & ExtrasExtrasUnsure

Do you hold a card issued by the Department of Veteran Affairs?

YesNo

DVA Card Type

GoldWhite

Card No.

Do you have an aged pension card, healthcare card or a DVA card

YesNo

CRN:

Expiry

Financial Consent

An out-of-pocket cost may arise when the amount covered by Medicare and/or your private health insurance does not cover the full fee of a service. We ask that your account for consultation be paid on the day of your appointment. Should you require a procedure on the day of consultation (such as photographs, biopsy or nasoendoscopy), we will bulk bill you (or charge your private health fund without gap payment) for this. Further discounts are at the discretion of Dr. Manzie. Should there be an outstanding account, further appointments may not be offered until this has been settled. We will provide you with a quote for any proposed procedure to ensure you are fully informed of any fees that may occur.

Privacy Note

To help provide ongoing quality health care, it is at times necessary to maintain a personal record that will contain information about you and your health. The following information may be contained within your record:

Personal details such as your name, address, date of birth
Financial information such as your Medicare card, private health insurance details and Government issued cards (such as DVA/pension details if applicable)
Your medical history including previous history, treatment details (outpatient appointments, operations, multidisciplinary meetings) and referrals to/from other medical specialists
Results including blood tests, biopsies, medical imaging, resection specimens including those sent by other medical specialists
Clinical photography

The information we collect and maintain is provided by you and arises during your course of care. We take the responsibility of maintaining the security of these files seriously and utmost care. Your file will be accessed by your medical specialist and others. Your files may be accessed by ancillary staff to address the administrative role within the practice.

Name *

Today's Date *

Patient/ Guardian Signature *

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MEDICAL HISTORY

Have you ever been diagnosed with Cancer? *

YesNo

What type of Cancer:

Cancer Treatment

Radiation TherapyChemotherapy

Please list all other medical conditions below:

Please list your operations below (including month / year):

Please list your current tablets and medications below (please include all herbal or over the counter medications):

Do you have allergies? *

YesNo

Please list allergy / reaction below:

Have you ever seen a vascular surgeon? *

YesNo

SOCIAL HISTORY

Do you drink alcohol? *

YesNo

If yes, how many drinks per day / week / month?

Do you smoke? *

YesNoEx-smoker

If yes, how many cigarettes per day?

How many years have you smoked for?

What year did you quit?

What kind of work do you / did you do?

To your knowledge, have you ever been exposed to noxious chemicals?

Yes NoUnsure

CONSENT

I agree to the information above being used for routine administrative and statistical purposes
I agree to the information contained within my medical record being used and shared between the health professionals involved in my care both within the hospital and community and reviewed for the purpose of quality improvement in the health, education and approved research
I agree to information contained within my medical record being presented and discussed at multidisciplinary team meetings at the discretion of the treating medical team
I agree for information relevant to my medical treatment being requested by and provided to healthcare practitioners who are involved in my care (i.e. medical specialists, dentists, speech pathologists, physiotherapists)
I agree for the use of clinical photographs to be used for the purpose of education of medical staff, allied health and for patients with similar medical conditions or for use on social media.
I agree for clinical photographs and my de-identified information to be included in medical presentations and publications.

I give my consent to the above terms & conditions. *

Name *

Today's Date *

Signature *

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