Patient Information Form - The Caps Clinic printable pdf download

patient information form

Title: ____________ First names: _____________________ Surname:___________________________

Address: ___________________________________________________________ Postcode: _________ Date of

birth: ______/______/________ Occupation: _________________________________________ Contact

Numbers: (h) __________________ (w) ____________________ (m) ______________________ Email:

__________________________________ Marital Status: _________________________________ Next of Kin:

_____________________________ Next of Kin Phone: ______________________________ Parents Names (if

patient is under 18 years): _________________________________________________

How did you hear about 360UV? __________________________________________________________

Medicare Number: ___________________________________ Card Ref No _______ Exp: ___________

Private Health Fund: _______________________________ Membership Number: __________________

Pension Number: __________________________________ Expiry: ______________________________ DVA

Number: __________________________________ Card Colour: White / Gold

Family Doctor: _____________________________ Suburb: ____________________________________

Referring Doctor: ___________________________ Suburb: ____________________________________ Would

you like your family doctor to receive information relating to this consultation?

Yes 

No 

Current Medications / Blood Thinning Medication eg Asprin / Vitamins: _____________________________

_____________________________________________________________________________________Known

Allergies: _______________________________________________________________________ Surgical /

Medical History: Diabetic / Heart Problems / Bleeding Problems: _________________________

_____________________________________________________________________________________ Do you

smoke?

Yes / No

How many per day? ____________________________________________

Please complete if you are seeing the Doctor for a full body scan

In undertaking this examination I recognise that whilst identification and storage of my moles with the use

of a ‘scanning system’ is the best opportunity available for the early discovery and monitoring of skin

lesions or a possible melanoma, it is not 100% guarantee of detection.

I understand that Skin Lesions/Melanomas can arise in any part of the body, so I hereby consent to

either:

Please tick one of the following:

 A full examination of my body including breasts and genitals

 A full examination of my body excluding genitals

 A full examination of my body excluding breasts and genitals

Privacy Statement: It is the policy of 360UV our patient’s personal health information will only be used or disclosed in the provision of a

patient’s care. The clinic has established a privacy policy in compliance with the National Privacy Act of 2001. Copies of this policy are

available on request.

Patient Information Form - The Caps Clinic