Please complete the form on this page prior to attending your appointment.

Contact Details / General Info

Your Name(Required)

Title First Name Middle Surname

Preferred Name (if different to above)

Date of Birth(Required)

Month(Required)

Year(Required)

Age

Weight (kg)

Height (cm)

Your Address(Required)

Street Address Address Line 2 Suburb Post Code

Phone (Home)

Phone (Mobile)(Required)

Phone (Work)

Your Email Address(Required)

What is your occupation?

What are your hobbies?

Medicare & Health Cover

Medicare Card Number(Required)

Reference Number(Required)

Expiry Date (Month)(Required)

Expiry Date (Year)(Required)

Do you have a Veterans' Affairs Card?(Required)

Yes, Gold

Yes, White

Card Number(Required)

Do you have private hospital health cover?(Required)

Yes

Name of your health fund(Required)

Membership Number

Is the patient a minor?(Required)

Yes

Parents Details (if patient is a minor)

Parents Name(Required)

Date of Birth(Required)

Month(Required)

Year(Required)

Parents Medicare Number(Required)

Reference Number(Required)

Expiry Date (Month)(Required)

Expiry Date (Year)(Required)

GP & Emergency Contact

Name of your GP(Required)

Name of Surgery(Required)

Name of Emergency Contact / Next of Kin

First Last

Phone Number(Required)

Relationship to you(Required)

Workers Compensation

Is this a Workers Compensation claim?

Yes

Employer / Company Name(Required)

Contact Name (Employer)(Required)

Phone Number(Required)

Employer Address(Required)

Street Address Address Line 2 Suburb Post Code

Name of Insurance Company(Required)

Claim Number(Required)

Case manager(Required)

Phone Number(Required)

Email(Required)

Date of injury/accident(Required)

Name of Rehabilitation Provider(Required)

Case Manager(Required)

Phone Number(Required)

Email address(Required)

Previous Treatments / Providers

Medical History

Do you have heart problems?

Yes

Please tell us more about your heart problems:(Required)

Do you have high blood pressure?

Yes

Please tell us more about your blood pressure:(Required)

Do you have any breathing problems?

Yes

Please tell us more about your breathing problems:(Required)

Do you have diabetes?

Yes

Tell us more about your diabetes:

Do you have stomach ulcers or reflux?

Yes

Tell us more about your ulcers/reflux:

Do you have kidney problems?

Yes

Tell us about your kidney problems:

Are you a smoker?

Yes

How many cigarettes do you smoke each day?

Do you take Asprin, Warfarin, or any other blood thinning medications?

Yes

Which medications do you take and how often?

Do you have any allergies to any medications?

Yes

Which medications are you allergic to?

Please tell us about any other medical conditions you have :

Please tell us about any previous (relevant) or major operations:

Please list all the medications you are CURRENTLY taking (including pain-relief, non-prescription and herbal medication):

Is there anything else you would like to tell us?

Medical Fee - Please check box(Required)

I agree that I am responsible for the payment of all fees to Dr Matthew Lawson-Smith (YARM Nominees Pty Ltd) for consultation, surgery or any reports requested on my behalf for Medico legal reasons and Workers Compensation claims.

As a patient of our medical practice we require you to provide us with your personal details and a full medical history, we that we may properly assess, diagnose, treat and be proactive in your health care needs.

We aim to protect the privacy and secure storage of your health information.

We require your consent to collect personal information about you and to use the information you provide in the following ways.

Administrative purposes in running our medical practice.
Billing purposes, including compliance with Medical and Health Insurance Commission requirements.
Disclosure to others involved in your healthcare including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following referrals.
For research and quality assurance activities to improve the individual and community health care and practice management. Usually information that does not identify you is used but should information that will identify you be required you will be informed and give them the opportunity to “opt out” of any involvement.
To comply with any legislative or regulatory requirements e.g. notifiable diseases.
For reminder letters which may be sent to you regarding your health care and management.

You can decline to have your health information used in all or some of the ways outline above but it may influence our ability to manage your health care to provide the best outcome for you.

Consent(Required)

I acknowledge and consent to the following;

I have read the information above and understand the reasons why my information must be collected. I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of health care and treatment given to me. I am aware of my rights to access the information collected about me, except in some circumstances where access may be legitimately withheld. I will be given an explanation in these circumstances. I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained. I hereby consent to the handling of my information by the practice for the purpose set out above, subject to any limitation on access of disclosure of which I notify this practice.

Your name (patient)(Required)

First Last

Signature (patient)(Required)

Your name (parent/guardian of child)(Required)

First Last

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