Please write as your name appears on Medicare Card
NEXT OF KIN DETAILS
ESCORT CONTACT DETAILS
Please note for your own safety, if you cannot provide an escort your procedure will need to be postponed.
OFFICE USE ONLY
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PATIENT PRE-ADMISSION HISTORY
ALLERGIES / SENSITIVITIES
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CONSENT FOR PROCEDURE
PART A: (To be completed by Patient)
The doctor whose name appears in Part B and I have discussed my present condition and the ways which it might be treated. The doctor has told me that
I agree that I have been given the opportunity to ask questions of the doctor whose name appears below 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
PART B: (To be completed by Proceduralist)
have informed (Patient)
Of the nature and material risks of the recommended procedure.
I have discussed with the patient the relevant aspects and risks of the anaesthetic and he/she has given consent to proceed.
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