Consultation Form



Level 4, 75 Grafton St.
Bondi Junction NSW
Tel: 02 9387 3900
Click for directions

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Please complete the form below to the best of your ability.
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Patient Details:
* First Name:    
* Last Name:
Date of Birth:
Age:
* Address:
* Suburb:
* Postcode:
* Phone:
Work Phone:
Occupation:
* Email Address:
Nearest Relative Name:
Nearest Relative Relationship:
Nearest Relative Phone:
Referring Doctor:
Referring Doctor Address:
Family Doctor (if different):
Family Doctor Address:
Health Fund Details:
Medicare No.:
Patient No.:
Valid Until:
Pension:
Repat. No.:
Health Fund: Yes     No
Name of Fund:
Member No.:
Health Questionnaire:
To assist us to provide the safest possible care for you, would you please inform us about your medical history.
Do you have any Medical Illnesses?(Please List)
Do you take any Medications, including Aspirin, Vitamins and Natural/Herbal products?
(Please List)
Are you Allergic to any Medication, Antiseptics, or Products?
(Please List)
Do you have a History of the Following? (Tick)
Asthma Healing Problems Bad Scars
Diabetes High Blood pressure HIV/AIDS Exposure
Hepatitis Spinal/Neck Problems Cold Sores
Wound Infections Contact Lenses Arthritis
Rheumatic Fever Blood Clots Heart Trouble
Do you use any Recreational Drugs? (Please List)
Daily Intake Smoking?
Daily Intake Alcohol?
Do you have any Psychiatric or Psychological problems, or have you seen a counsellor for Mental Health Problems?(Please List)
Have you had any Previous Operations?(Please List)
Have you ever had any problems with Previous Operations or Recovery from an Operation?(Please List)
Have you or a Family Member ever had Problems with any Local or General Anaesthetic? Yes     No
Have you or a Family Member ever had Problems with excessive Bleeding for any reason?
(Please List)
Thank you for providing us with this information.
* Additional Comments:
Consent:
* I give Permission for details of my consultation to be used in communication with other Health Care Professionals who are involved in my care Yes     No
Where did you hear about Silkwood Medical?
Referring Dr / Other Dr Name:
Word of Mouth:
Events:  The High Tea
Advertising Material (Tick):
Magazine:
Newspaper
Television
Radio
Internet
Are you interested in receiving Promotional Material from Silkwood Medical including special offers? Yes     No
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