Robotic Upper Gastrointestinal,
Pancreatic & General Surgeon
(02) 9480 4250
Book an Appointment

Patient Intake Form

New Patient Intake Form

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Veterans Card

Personal Health Information

Alcohol
Smoking
Taking Aspirin or Blood Thinners?
Imaging (US/CT/MRI)
Bring all reports with you

Fees

This is a private practice and we do not bulk bill. The fees charged by this practice are generally on par as recommended by the Australian Medical Association and are payable at the time of consultation. We will endeavour to provide you with informed financial estimation prior to any planned procedure but this may not always be possible in emergency cases. Please feel free to enquire regarding costs at any stage of your care. The following payment methods are available: Cash, Cheque, EFTPOS (Visa, MasterCard or Debit Cards).

Privacy Note

I agree to allow the doctors and staff at this practice to access all relevant information regarding my medical conditions. I agree that the doctors and staff may be required to forward/obtain information about my medical condition/history from my referring doctor or other health care providers. I understand that my clinical records may be accessed or reviewed by staff at this practice.

Consent

Clinical photographs will be taken as part of my consultation and procedures, my clinical photographs may be used for medical educational purposes (doctors/nurses/medical students only). Details of my consultation can be used in communication with other health care professionals who are involved in my care. Additionally, I give my permission for my clinical photographs to be used for public education purposes.
I DECLARE THAT TO THE BEST OF MY KNOWLEDGE THE INFORMATION I HAVE PROVIDED ON THIS FORM IS ACCURATE
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