Patient Registration"*" indicates required fieldsX/TwitterThis field is for validation purposes and should be left unchanged.Personal detailsName* First Last Date of birth*OccupationAddress Street Address Suburb Postcode Email* Phone*Work phoneEmergency phoneNext of kin details (family member or friend / medical power of attorney)Name First Last Relationship to youPhoneCommunicationsDo you consent for Mr Jalil or his staff to leave a message with your Emergency Contact Person? Yes NoDo you consent for Mr Jalil or his staff or his staff to correspond with you via email? Yes NoDo you consent for Mr Jalil or his staff to leave a message on your Home/Mobile Number? Yes NoGP’s DetailsName Dr.Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Practice Address Street Address Suburb Postcode Contact numberMedicare and Private Health Insurance DetailsMedicare NumberRef. no.Exp. datePrivate Health Insurance Yes NoFund nameFund numberLevel of coverConcession CardsAged or Disability Pension NoExp. DateDept. Veterans Affairs Card NoColour White GoldExp. DateHealth Care Card NoExp. DateWorkCover Details (If applicable)Is this visit related to a WorkCover injury Yes NoW/C Claim NoDate of InjuryInsurerEmployerClaims Officer Name First Last Claims Officer PhoneClaims Officer FaxTAC Details (If applicable):Date of accidentClaim numberClaims Officer Name First Last Claims Officer PhoneClaims Officer FaxMedical HistoryPlease list current medications:Please list previous surgical procedures:OperationYearOperationYearOperationYearDo you smoke cigarettes? Yes NoAmount of ciggarettes per dayYears of being a smokerDo you take any blood thinning agents (eg Warfarin, Plavix, Aspirin, Asasantin etc)? Yes NoDetailsDo you have any allergies? Yes NoDetailsPlease indicate if you suffer or have suffered from any of the following:Deep venous thrombosis (DVT) Yes NoPulmonary embolism (PE) Yes NoHeart Attack Yes NoOpen Heart Surgery Yes NoEpilepsy Yes NoStroke Yes NoBleeding disorder Yes NoAngina Yes NoCoronary Stent Yes NoDiabetes Yes NoMigraines Yes NoAsthma / COAD Yes NoDeep venous thrombosis (DVT) Yes NoOther detailsAI Transcription & Privacy ConsentAI Transcription Consent I consent to the use of secure AI-assisted transcription during my consultation to assist with the preparation of accurate clinical notes. I understand that I may decline or withdraw my consent at any time without affecting my care.All information collected by this practice will be used for providing healthcare. Collection and utilization and storage of this information will be compliant with the 2001 Health Records Act.Privacy Consent I consent to Mr Fahmi Jalil collecting and storing my health information:Signature*Your NameYour NameDate Name First Last Payment PolicyIn the event that an invoice remains unpaid we will engage a debt collector to collect the debt and add any commission charged to your overall debt.SignatureYour NameYour NameHow did you hear about us?Referred by Doctor: DRDr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Or (please check appropriate referral source): Our Website Royal Australian College of Surgeons (RACS) website Google Search Yellow Pages White Pages Personal recommendation OtherPersonal recommendation details:Other details:
