Patient Information Form

Patient Information Form

PATIENT DETAILS

First Name

Last Name

Preferred Name

Date of Birth *

Gender

MaleFemale

English is a Second Language

YesNo

Do you require an interpreter? If So, which dialect?

PATIENT CONTACT DETAILS

Home Phone

Mobile Phone

Address

Suburb

Postcode

State

MEDICARE

Medicare Card No.

Reference No. (number next to your name)

Is the patient under 18 years of age?

YesNo

IF patient is under 18, we require caregiver Medicare Card details:

Parent Full Name *

Parent Date Of Birth *

Parent Medicare Card No.

Parent Reference No. (number next to your name)

PRIVATE HEALTH INSURANCE

Do you have Private Hospital Insurance Cover AND have held your cover for more than 12 months?

YesNo

Health Fund Name

Membership No.

Level of Cover (Gold, Silver, Bronze)

PENSION / HCC/DVA Card

Do you have a pension, healthcare or DVA card?

YesNo

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

NEXT OF KIN CONTACT DETAILS

Do you give permission for your Next Of Kin to be provided with your information (i.e. appointments?)

YesNo

Next of Kin - Name

Next of kin - Mobile Phone

REGULAR GP / INTERESTED PARTIES

GP Doctor’s Name

GP Practice name

Interested Party Doctor Name

Interested Party Practice Name

DVA No.

CONSENT TO USE AI TRANSCRIPTION

Our practice uses AI transcription technology – i-Scribe captures and transcribes conversations between you and Dr Floreani. Dr Floreani may have i-Scribe running in the background during your consultation. i.Scribe will listen to, and transcribe, your consultation. The transcribed notes will be reviewed and verified by Dr Floreani before being added to your medical record. All notes, letters, and transcriptions are securely stored and are only accessible to authorized personnel in this clinic, for a short period of time. The information captured by i-Scribe is treated with confidentiality in accordance with the Privacy Act 1988. Your personal and medical information will not be shared with any unauthorised parties. You have the right to withdraw your consent at any time without affecting your ongoing care. By signing below, you consent to the use of i-Scribe during your consultation and the transcription of your conversations being used for the purpose of medical documentation. *

Patient/ Guardian Signature

Draw signature|Type signatureClear

Today's Date

Health Questionnaire

HEALTH INFORMATION

Have you seen a surgeon in the past for any ENT related surgery? This includes Rhinoplasty or Sinus surgery.

YesNo

If you have seen a surgeon in the past for ENT conditions, what was the treatment and approximate date(s) of your treatment?

Do you have any functional (use) concerns with your nose? If so, what specifically?

Do you have any cosmetic (appearance) concerns with your nose? If so, what specifically?

Do you have a history of Body Dysmorphic Disorder or any other Psychiatric illness?

YesNo

MEDICATIONS

Do you take any regular medications?

YesNo

Please list any medications you are currently taking

Medication Name

Dose

Medication Name

Dose

Medication Name

Dose

ALLERGIES

Do you have any allergies?

YesNo

Allergy

Reaction & Severity (i.e. rash, illness)

Anaphylactic Reaction? *

Yes No

Allergy

Reaction & Severity (i.e. rash, illness)

Anaphylactic Reaction? *

Yes No

RECREATIONAL ACTIVITIES

Do you smoke?

YesNo

Do you use recreational drugs?

YesNo

CONSENT TO COLLECT INFORMATION

In order for us to provide you with the best service possible, and to adequately assess and treat you, we need your consent to collect personal information. We use your information according to the Privacy Act 1988 (Privacy Act). By signing below, you acknowledge that you have read and understood the information provided above. You consent to your personal information being used within guidelines of the Privacy Act 1988. You understand that while you are not obliged to disclose your personal information, failure to do so may compromise the quality of care you receive. *

Patient/Guardian Signature

Draw signature|Type signatureClear

Date

Save and Complete Later