First Name

Last Name

Address

City

State

Post Code

Email Address

Date of Birth

Home Phone

Mobile Phone

Medicare Number

Medicare Reference No.

Medicare Expiry

Private Health Fund Name

Private Health Fund Number

Referring Doctor Name

Referring Doctor Suburb

Next of Kin Name

Next of Kin Contact No.

Next of Kin Relationship

General Practioner Name

General Practioner Suburb

Medical History Medical History Yes I have relevant Medical History No I do not have relevant Medical History

Existing Diagnosed Conditions

Previous Operations

Other Information

I give my consent to Dr Jo Schoeman, or his agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Dr Jo Schoeman, or his agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. I give my consent to Dr Jo Schoeman, or his agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Dr Jo Schoeman, or his agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. Yes I consent to the above