Personal Details Title * - Select -MrMrsMissMsDr First Name * Last Name * Preferred name Occupation Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Sex * Male Female Genetic Sex (not Gender). Contact Details Address line 1 * Address line 2 Town/Suburb * State * ACTNSWVicSAQldNTWATas Postcode * Email * Home Phone Work Phone Mobile Phone Preferred Contact Method * - Select -EmailHome PhoneWork PhoneMobile Emergency Contact Details First Name Last Name Phone Relationship Membership Details Medicare Number 10 Digits. Medicare IRN 1 digit next to cardholder's name. Medicare Expiry (MM/YY) Your Medicare card expiry date is located on the bottom left of your Medicare Card. Private Health Fund Name eg. HCF, NIB, Bupa. Private Health Fund Membership Number Are you a member of the Department of Veterans Affairs (DVA)? * Yes No Department of Veterans Affairs (DVA) Member Number DVA Card Level - None -GoldWhiteOrange Do you require DVA transport booked for you? Yes No Medical Details Medical History * Yes – I do have relevant medical history No – I do not have relevant medical history Covid-19 Have you recently travelled internationally or domestically? * Yes No Have you recently had close contact with any persons with COVID-19? * Yes No Have you recently or currently experienced any symptoms? * Yes No Fever greater than 37.5°C, Difficulty breathing, Cough, Sore Throat, or Fatigue. General Health Existing, diagnosed conditions Allergic reactions Drugs or other causes Medications Do you take any type of anticoagulant (blood thinner)? * Yes No E.g.: Plavix, Xarelto, or Warfarin. Prescribed anticoagulants * Do you take antidepressants? * Yes No Prescribed antidepressants * Are you a diabetic? * Yes No Are you insulin dependent? * Yes No Current Medications Including over the counter medications. Current Vitamins or Dietary Supplements Surgeries Do you have metal implants? * Yes No Do you have a Pacemaker? * Yes No Do you have Stents? * Yes No Previous operations Doctor and Specialist Details Doctor Details Referring Doctor Name Referring Doctor Phone Specialist Details If there are any other specialists that require clinical information please fill the information below. Specialist Name Specialty -- Please select --BariatricsCardiologyColorectalDermatologyEar Nose and ThroatEndocrinologyGastroenterologyGeneral SurgeonGeneral PhysicianGeneral PractitionerNeurosurgeryObstetrics and GynaecologyOncologyOphthalmologyOrthopaedicsPaediatricsPathologyPlastic SurgeryRadiologySpinalUrologyVascular - Endovascular Specialist Medical Practice Name Specialist Phone + More Consent to release medical information I give my consent to Dr Andrew Renaut, or his agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Dr Andrew Renaut, or his agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. For more information view our Patient Information Privacy Statement. Consent * Yes, I consent to the above. Website Submit
