Medical Form Patient InformationName(Required) DOB(Required) Date(Required) DD slash MM slash YYYY Address(Required) Suburb(Required) Post Code(Required) Phone(Required)Occupation(Required) Have you been to see Dr Widdowson before?(Required) Yes No When?(Required) 1. Have you had any of the following? (Tick the appropriate answer)Heart/ vascular disorder(Required) Yes No Rheumatic fever/arthritis(Required) Yes No Blood disease/bleeder(Required) Yes No Diabetes(Required) Yes No AIDS/HIV(Required) Yes No Liver/Kidney Disease(Required) Yes No Blood pressure problem(Required) Yes No Asthma/Epilepsy(Required) Yes No Hepatitis A/B/C(Required) Yes No Deep vein thrombosis(DVT)(Required) Yes No Any other serious illnesses(Required) List any previous surgeries(Required) 2. Do you suffer from breathlessness, swollen ankles or chest pain ?(Required) Yes No 3. Are you at present receiving any medical treatment?(Required) Yes No 4. List any tablets or medicines you are taking?(Required) 5. LADIES - Are you pregnant?(Required) Yes No Baby due date:(Required) 6. Are you a smoker?(Required) Yes No if yes how many a day?(Required) 7. Have you ever had the following:Allergies to any drugs? Been treated for cancer? Unfavourable reaction to local or general anaesthetic? 8. Where did you hear about us(Required) Doctors referral - may we contact him/her Friend/Family Web Site Yellow Pages Radio Magazine Doctor(Required) Yes No (Name optional) 9. Medicare Number:(Required) Exp:(Required) 10. Private health fund name(Required) Membership Number(Required) 11. As a client of the lotus institute you will be entitled to special privileges and exclusive invitations Email address is:(Required) A deposit of $1000 is required at the time of booking surgery to secure the booking. This deposit is non-refundable in the event of surgery being cancelled by you, or payment not being met 4 weeks pi for to surgery without prior arrangement. The purpose of this non-refundable deposit is to reduce cancellations on theatre lists and thereby reducing waiting times for you. The balance of your surgery fee Is required to be paid no later than 4 weeks prior' to the scheduled surgery date. Please note, if you cancel your surgery inside 4 weeks you will forfeit 50% of your surgery fees. If you cancel within 2 weeks prior to surgery you will forfeit 100% of your surgery fees. RESCHEDULING: We understand that events can happen suddenly that will result in the patient wishing to reschedule their surgery to another date. Rescheduling will incur no fee if done prior to two weeks from the scheduled surgery date. Within two weeks will result in a $500 rescheduling fee and 1 week prior to the scheduled surgery date will result In d IOS5 Of the full deposit, If you reschedule, then subsequently cancel the new surgery date, the full cancellation policy conditions will apply. Dr Widdowson may, at his discretion, apply whole or part of the forfeited fee to the cost of any further or subsequent surgery.Patient /Guardian’s Name(Required) Date(Required) DD slash MM slash YYYY CAPTCHA
