Please write as your name appears on Medicare Card
NEXT OF KIN DETAILS
ESCORT CONTACT DETAILS
OFFICE USE ONLY
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PATIENT PRE-ADMISSION HISTORY
ALLERGIES / SENSITIVITIES
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CONSENT FOR PROCEDURE
To be completed by Patient
I have been informed that:
I agree that I have been given the opportunity to ask questions of a GME doctor onsite on this day and understand the nature of the procedure and undergoing the procedure carries risks. I am satisfied with the answers and information I have received.
I have been advised of the material risks associated with this procedure.
I understand that whilst I am in hospital, I will receive care, medications, tests and examinations as necessitated by the procedure I am undertaking.
I acknowledge that the hospital has made available to me Patient Rights and Responsibilities, details on how to make a complaint as well as Health Information Collection Disclosures.
OR, I certify the patient is unable to sign
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