PERSONAL DETAILS

!Ms !Miss !Mrs !Mr !Master !Dr !Prof !Other Date of birth: ___ /____ /____ Given name: ______________________________Surname: ___________________________ Address: ____________________________________________________________________ Phone: home __________________ work_________________ mobile___________________ Email: ______________________________________________________________________ Please tick: Retired ! Unemployed ! Employed ! >> occupation:__ ____________ CLAIM DETAILS

Medicare number: __________________________ Ref #: ____________ Exp date: ____ /____ Private health insurance: ! no ! yes Fund name: ________________ Member #:_________

! extras ! hospital CONCESSION CARD

Aged or disability pension #: ____________________________________ Exp date: ____ /____ Dept. Veterans Affairs card #: ____________________ ! White ! Gold Exp date: ____ /____ Health Care Card #: __________________________________________ Exp date: ____ /____ WorkCover (if applicable) Claim #: ___________________________ Insurer: _______________ PRIVACY

Do you consent to communication being sent to your family doctor or GP? ! yes ! no General Practitioner’s details (only complete this section if your GP was not your referring doctor) Name: _____________________________________________________________________ Practice address: ____________________________________________________________

Are you happy for Dr David Sharp to call your next of kin after any operations? ! yes ! no Are you happy for information to be given to your next of kin over the phone? ! yes ! no Next of kin name: ______________________________Contact number/s: _________________

REFERRAL SOURCE How did you hear about Dr David Sharp? ! Google ! Referred by doctor ! White pages

! Personal recommendation: ___________________ Other: ___________________

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CONFIDENTIAL PATIENT INFORMATION

MEDICAL HISTORY

To ensure optimal medical and surgical care, it is very important that you answer the following questions thoroughly and honestly please. CURRENT WEIGHT: _____________kg HEIGHT: _____________cm CARDIAC: have you ever suffered from the following? ! Heart attack ! Chest pain

Do you have a pacemaker? ! yes ! no

Have you had any of these: Cardiac stents ! yes ! no Bypass surgery ! yes ! no

Have you ever suffered from: Stroke ! yes ! no TIA (mini stroke) ! yes ! no Have you ever been treated for, or diagnosed with (tick if applicable): Anxiety ! Depression !

PTSD ! Biopolar ! Body dysmorphia ! eating disorder ! psychosis !

DIABETES: Do you suffer from Diabetes? ! yes ! no

> If yes, is your diabetes controlled by: ! diet ! tablets ! insulin injections

ASTHMA: Do you suffer from Asthma? ! yes ! no

> If yes, how is your Asthma managed? _______________________________

EPILEPSY: Do you suffer from Epilepsy or have ever experienced seizures? ! yes ! no

DVT/PE: Have you ever suffered from DVT or Pulmonary Embolism (clots in lungs/legs)? !yes !no

SMOKING: Are you currently a smoker? ! yes ! no > If yes, how many per day: ____________ If you have allergies to any creams, lotions, adhesives, seafood, latex, food or vitamins, please list: __________________________________________________________________________ MEDICATIONS

Do you take any blooding thinning medications, such as: ! Asprin ! Warfarin ! Plavix/Clopidogrel

Please list all medications you are taking, including over the counter, herbal or vitamin preparations: __________________________________________________________________________ SURGERY

Have you had any previous surgery? ! yes ! no > If yes, please provide details (surgical procedure, and approx date):

_____________________________________________________________________________

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MEDICAL QUESTIONNAIRE

The information requested above and relevant health information may be sent to other health professionals (eg. your anaesthetist) or organisations (eg. hospitals, pathology collection centres) where this is needed to provide your health care. As required by the Commonwealth Privacy Act 1988 we request your consent to sending this information to these practitioners and organisations. Information will only be sent for the purpose of providing your health care. You may request to review the information we have on file about you for the purposes of checking that the information is correct. During the post operative period, if you have any post operative complications, you may choose to send us questions or clinical photos for your nurse and Dr Sharp to review. In signing this form and choosing to transmit images or questions to us via email or mobile phone post operatively, you acknowledge that these images may be transmitted to relevant clinicians via their devices (phones, iPad, email) for them to urgently review for post surgical care as required. By signing below you consent to Dr David Sharp sending your personal and health information to other persons or organisations where this is necessary to provide your health care.

For almost all patients, cl inical photography wil l be taken to assist in your care. This includes before and after photos/videos in the clinic, as well as intraoperative photos/videos during surgery. By signing this form, you provide permission for these images to become part of your confidential medical records. We also would like to ask you for permission to use these photos/videos for educational purposes in addition to their use as part of your medical care. All images used for purposes other than the medical records are de-identified; except in facial surgery cases where specific written permission must be given for identifiable images to be used. Names are not used and as far as possible, identifying factors are masked. These photos are extremely helpful in teaching other doctors and helping other patients make an informed decision about their surgery, as you may have found yourself when researching your procedure. We are very grateful to those patients who permit us to share their images, and we are able to de-identify them if you wish – however you are under no obligation to agree to this. Do you consent to your de-identif ied before and after cl inical photos being used:

• For the purpose of teaching other health professionals such as doctors, nurses and associated students? ! yes ! no

• In publications eg articles in medical journals? ! yes ! no • To educate other patients

in clinic and online? ! yes ! yes, but only de-identified ! no

Images will not be sold or transferred to any other entity for purposes that have not been agreed to. Declaration: I grant permission for photographs of me to be used in the formats indicated above. I represent that I am at least 18 years of age, have read and understand the foregoing statement, and am competent to execute this agreement.

PATIENT SIGNATURE: _______________________________________ Date: ____ /____ /____

PRIVACY

PHOTOGRAPHY CONSENT