General Information

Name *

Surname *

Date of Birth *

Phone Number *

Email *

Address *

Street address *Street address line 2

City *

State *

Postcode *

Country

Emergency Contact Information

Emergency contact

Phone

Emergency contact’s relationship to you

Medicare Details

Medicare Number *

Individual Reference Number (IRN) *

Expiry Date *

Private Health Insurance

Private Health Fund or Company Name

Membership Number

Medical History

Have you in the past been diagnosed with, prior treated for, or currently on treatment for any of the following? (please tick all that apply)

Heart attackChest painStrokeSeizuresAsthmaPacemakerCardiac stentDVT/PEDiabetes

Do you have any allergies? *

YesNo

Allergies

Do you have any metal hypersensitivity or sensitivity to jewellery? *

YesNo

Do you take any blood thinners/antiplatelets/anticoagulantsDo you take any blood thinners/antiplatelets/anticoagulants *

YesNo

Smoking History *

Current SmokerFormer SmokerNo Smoking History

When did you quit smoking?

Have you ever had any surgery? *

YesNo

Have you had any problems with anaesthetics (general or local)?

YesNo

Please detail prior problems with anaesthetics below:

Procedures

Which procedure/s would you like to discuss?

Total hip replacementTotal knee replacementACL reconstructionFracturesPatella stabilisationOther knee ligament reconstructionMeniscal repairOther procedure

Consent

I confirm that above information I have provided is true, complete and accurate. *

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Date

Complete Form

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