Patient Registration Form | East Coast Plastic Surgery

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PROCEDURES

BREAST

Breast Augmentation (Enlargement)

Mastopexy (Breast Lift)

Mammaplasty (Breast Reduction)

Explant (Removal of Implants)

Breast Reconstruction

Gynaecomastia (Male Breast Reduction)

BODY

Abdominoplasty (Tummy Tuck)

Liposuction

Labiaplasty

Postpartum (Abdominoplasty & Breast Augmentation)

Female to Male (FTM) Top Surgery

FACE

Brow Lift

Upper Blepharoplasty (Eyelid Surgery)

Rhytidectomy (Facelift / Necklift)

Otoplasty (Ear Surgery)

SKIN

Skin Cancer Removal

Scar Revision

Benign Skin Lesion Removal
FORMS
FORMS

Patient Registration Form

Patient Photo Release Form

Simple Cosmetic Surgery Enquiry Form

Detailed Cosmetic Surgery Enquiry Form
GALLERY
OUR TEAM
CONTACT
CALL 1300 668 254

CALL 1300 668 254

Patient Registration Form

To help us provide you with the best possible care, please complete the Patient Registration Form below. If you have any questions or need assistance, our friendly team is here to help.

Contact Details

Title

First Name

Last Name

Middle Name

Preferred Name

Maiden Name

D.O.B

Occupation

Gender

Pronouns

Home Phone

Work Phone

Mobile Phone

I would like to receive SMS

Yes No

Email Address

I would like to receive emails

Yes No

Residential Address

Postal Address

Medicare & Health Fund Details

Medicare Number

Ref

Expiry Date

I consent to be bulk billed, where applicable

Do you have Private Health Insurance (hospital cover)?

Yes No

Fund Name

Member Number

Ref #

Expiry Date

Name on Card

First Name

Last Name

Do you have a DVA card?

Yes No

DVA #

Card Type

Expiry Date

Name on Card

First Name

Last Name

Are you under 18 years old?

Yes No

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

Are you happy for information to be given to your next of kin over the phone?

Yes No

Referring Doctor Information

Please tick if you do not want any correspondence to be sent to your referring doctor and or / GP.

Referring Doctor Name

Practice Address

GP Name

Practice Address (if different to referring doctor)

Referral Source

How did you hear about ECPS?

Which Doctor are you seeing?

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)

Do you have or have you had any of the following conditions? (tick whichever applies)

High blood pressure Heart failure Asthma Diabetes Thyroid disorders GERD Epilepsy or seizures Stroke Chronic kidney disease Autoimmune conditions (if yes provide details) Anaemia Blood clots Osteoarthritis Diabetes Cancer HIV Hepatitis

Please list any other medical conditions not listed above

Are you pregnant?

Yes No

Are you currently a smoker or vaper?

Yes No

If yes, how many per day?

Do you have a family history of cancer, strokes or blood clots?

Yes No

If yes, please provide details

Mental Health History

Have you received treatment for, or been diagnosed with any of the following mental health conditions?

Anxiety Depression PTSD Bipolar disorder Body dysmorphia Eating disorders Psychosis Other

If yes to any of the above, please provide details

Allergies

Do you have allergies to any anaesthesia, creams, lotions, adhesives, seafood, latex, food, medications or vitamins?

Yes No

If yes, please provide details

Medication

Do you take any blood thinning medication?

Yes No

These?

Asprin Warfarin Plavix / Clopidogrel Other

If other

Please provide a list of all medications you are currently taking, including over-the-counter products, herbal supplements and vitamins.

Surgery

Have you had any previous surgery?

Yes No

If yes, please provide details

Agreement and signature

I understand that payment of the account is my responsibility and that Medicare or my health insurer will not cover the amount fully.

Signature

Date

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 health information as outlined.

Please sign below to indicate your agreement with the above terms.

Signature

Date

Photography 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.

Signature

Date

CONTACT US

T: 1300 668 254
e: info@ecplasticsurgery.com.au

Location

Suite 6, Level 5, 123 Nerang Street, Southport QLD

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PROCEDURES

Breast Augmentation (Enlargement)

Mastopexy (Breast Lift)

Mammaplasty (Breast Reduction)

Explant (Removal of Implants)

Breast Reconstruction

Gynaecomastia (Male Breast Reduction)

Abdominoplasty (Tummy Tuck)

Liposuction

Labiaplasty

Postpartum (Abdominoplasty & Breast Augmentation)

Female to Male (FTM) Top Surgery

Brow Lift

Upper Blepharoplasty (Eyelid Surgery)

Rhytidectomy (Facelift / Necklift)

Otoplasty (Ear Surgery)

Skin Cancer Removal

Scar Revision

Benign Skin Lesion Removal

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Dr. Luke Stradwick (MED0001189830), Dr. Fu-Yu (Mike) Yang (MED0002416925) and Dr. Daniel Williams (MED0001663694) are Fellows of the Royal Australasian College of Surgeons (FRACS) and are registered as specialist plastic surgeons in surgery – plastic surgery. Membership in FRACS and the Australian Society of Plastic Surgeons (ASPS) requires extensive specialist training and qualifications in plastic and reconstructive surgery. Dr. Stradwick and Dr. Yang are committed to delivering care in line with the highest professional standards.

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