Contact Details
First Name
Last Name
Middle Name
Preferred Name
Maiden Name
D.O.B
Occupation
Home Phone
Work Phone
Mobile Phone
Email Address
Residential Address
Postal Address
Medicare & Health Fund Details
Medicare Number
Ref
Expiry Date
Fund Name
Member Number
Ref #
Expiry Date
Name on Card
First Name
Last Name
DVA #
Expiry Date
Name on Card
First Name
Last Name
Please provide details of parent or guardian for Medicare processing
First Name
Last Name
D.O.B
Relationship
Medicare Card #
Next of Kin/Emergency Contact
First Name
Last Name
Relationship
Mobile Phone
Referring Doctor Information
Referring Doctor Name
Practice Address
GP Name
Practice Address (if different to referring doctor)
Referral Source
How did you hear about ECPS?
GP referral
Word of mouth
Social media
Previous patient
Friends or family
Other – please specify
Which Doctor are you seeing?
Dr Stradwick
Dr Mike Yang
Other
Medical History
To ensure optimal medical and surgical care it is very important that you answer the following questions thoroughly and honestly.
Current Weight (kgs)
Current Height (cms)
Please list any other medical conditions not listed above
If yes, how many per day?
If yes, please provide details
Mental Health History
If yes to any of the above, please provide details
Allergies
If yes, please provide details
Medication
If other
Please provide a list of all medications you are currently taking, including over-the-counter products, herbal supplements and vitamins.
Surgery
If yes, please provide details
Agreement and signature
Privacy Consent
We value your privacy and are committed to safeguarding your personal and health information. By signing this form, you agree to the collection, use and disclosure of your personal and health information as follows:
Collection and Use of Information:
We collect your personal and health information primarily to provide healthcare services to you.
This information is also used for managing our practice operations, including audits, accreditation processes, billing, and staff training.
Disclosure of Information:
Your information may be shared with third parties involved in your healthcare, such as Medicare Australia, private health insurers, government departments and other healthcare practitioners.
Post-operative Communication:
During the post-operative period, if you have any concerns or complications, you may choose to contact us and send clinical photos or questions.
By signing this form and choosing to send images or questions via email or mobile phone, you understand that these may be reviewed by our clinical team on their personal devices.
Access to Privacy Policy:
Our complete Privacy Policy is accessible here .
Consent Acknowledgement:
You confirm that you have read and understood our Privacy Policy and consent to the collection, use and disclosure of your personal and heh information as outlined.
Please sign below to indicate your agreement with the above terms.
Date
Privacy Consent
I acknowledge that photographs will be taken of me or parts of my body before and after surgery by a member of the East Coast Plastic Surgery staff in their facilities. I give consent for East Coast Plastic Surgery to use these photographs under the following conditions:
The photographs will be stored securely in a password-protected practice management software accessible only to surgeons and staff of East Coast Plastic Surgery. They may be used for educational purposes on the East Coast Plastic Surgery website, social media platforms, and within the clinic. Additionally, they may be used in clinical presentations to educate other healthcare professionals.
I understand that East Coast Plastic Surgery will handle the photographs with respect and professionalism. I consent to their use for public education purposes under the condition that my identity is not disclosed through my name or any identifying marks at any time during their use or publication.
By signing this form, I confirm my consent and acknowledge that this form supersedes any previous photo or privacy consent forms dated prior to today. I understand that I may revoke this consent at any time by submitting a written request or completing a new form.
Date
Send
