Patient Information Form - Radien Dermatology

Welcome to the Radien Dermatology Patient Information Form.

Please complete the form below for signing when you come in for your appointment.

"*" indicates required fields

Your Title*

Name

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone (Work)

Phone (Home)

Phone (Mobile)

Best Email Address*

Date of Birth

Gender*

Occupation*

Medicare Number*

Medicare Number

Number next to your name & Expiry

Patients Name*

First Last

Name of referring doctor

First Last

Name and address of GP (if not refering doctor)

If under 18 years old please complete the following for Medicare Purposes

Mothers Name

Phone

Date of Birth

Ref. on Medicare Card

Fathers Name

Phone

Date of Birth

Ref. on Medicare Card

THIS PRACTICE DOES NOT BULK BILL.

Do you have a Pacemaker?*

Have you had heart valve or joint replacements?*

Are you taking any blood thinning medications?*

If Yes, please select.

What medications and/or creams are you using?*

Do you have any ALLERGIES?*

Please List (eg. Penicillin, Local Anaesthetic, Band-aids)

Please note: If a skin biopsy or an excision is performed, the tissue sample we be sent to pathology. The pathologist will bill you for this. Medicare rebates apply.

** Payment for consultation is required on the day. If this is inconvenient, please see our receptionist to book another appointment.** Thank you for your assistance.

I AGREE TO PAY ON THE DAY FOR THE CONSULTATION. I UNDERSTAND THAT EXTRA CHARGES APPLY FOR ANY PROCEDURES PERFORMED.

Signed ........................................................ Date ..........................

The Privacy Act prevents us from obtaining information regarding your medical history, previous medical records, test results, letters and other documents from health practitioners without your prior written consent

It also prevents us from releasing any information regarding your medical history, previous medical records, test results, letters and other documents to other medical practitioners without your prior written consent

If we do not have all your medical information, treatment and followup may be very difficult

Obtaining and/or releasing such information may often be required in order for the Doctor to make an informed decision regarding your treatment and may also be required during the process of booking you in for tests or procedures.

By signing this form, you give Radien Dermatology the right to store, obtain and/or release information regarding your medical history, previous medical records, test results, letters and other documents to/from other medical practitioners or hospitals.

Name ........................................................ Date of Birth ..........................

Signature ........................................................ Date ..........................

I agree and will sign:*

To pay on the day of consultation

The Privacy Consent Form

Name

This field is for validation purposes and should be left unchanged.