Registration Form First NameLast NameTitleDate of Birth MM slash DD slash YYYY OccupationAddress & PostcodeEmail Address (for contact about appointments etc)Which numbers may we call you regarding appointments, results etc Mobile Home MobileHomeCan we leave messages or texts for you identifying this practice as the caller ? Yes No Nominated Person / Next of KinRelationshipMemberships:Health FundMember NumberMedical Conditions and TreatmentDo you have any of the medical conditions listed below ? Please tick Angina (heart pain) Respiratory Illness (lung problems) Cancer Hypertension (high blood pressure) Bleeding Disorder Chicken Pox or Shingles Diabetes (high blood sugar) Hepatitis (Liver virus or disease) Recent Viral Illness (Flu) Renal Disease (Kidney problems) HIV / AIDS Have you experienced any of the medical issues listed below? Please tick Deep Vein Thrombosis (blood clots in the leg) Difficulties with anaesthetics Pulmonary embolism (blood clots in the lung) Infections (such as MRSA) Heart Attacks HeightcmsWeightKgsMEDICATIONSWhich medications are you currently taking . Please take particular care to list any blood thinning medications such as aspirin, warfarin and fish oil.Are you Allergic to any Medications Yes No If Yes specifyPlease List Major operations or surgery you have previously hadHave you suffered any major complications from past operationHabitsAlcohol Never Average number of drinks each day Smoking Never Average number cigarettes each day Agreement and SignaturePrivacy Agreement - In order to comply with the privacy Laws (Privacy Act Amendments - Private Sector - Act 2000) your agreement to the following statement is required. I agree to allow Dr Drielsma access to all relevant information regarding my medical conditions. I understand that Dr Drielsma may be required to forward information about my medical condition or history to other health care providers. I understand that to provide the highest medical care, my clinical records may be accessed or reviewed by staff in this practice.Use of e-mail I agree to the use of my e-mail address for correspondence relating to Sydney Cosmetic Plastic Surgery, including marketing material. Sydney Cosmetic Plastic Surgery will never provide these details to third parties and I can unsubscribe at any time.Use of e-mail Yes No Photography Policy I agree and accept that all cosmetic patients have before and after photos taken which are kept with your records. On some occasions Dr Drielsma will use these photos, with reasonable identity protection, for educational or marketing purposes. If you prefer your photos not to be used in this way, please tick this box.Photography Policy* Opt out SignatureDate MM slash DD slash YYYY
