General Information

Name *

Surname *

DOB *

Mobile *

Email *

Address *

Street

City

State

Postcode

Medicare Details

Medicare Number *

Individual Reference Number (IRN) *

Expiry Date *

Private Health Insurance

Private Health Fund or Company Name

Membership Number

Emergency Contact

Next of kin/Emergency contact name *

Next of kin/Emergency contact number *

Medical History

Do you have any allergies? *

YesNo

Allergies

Smoking History

Current SmokerFormer SmokerNo Smoking History

When did you quit smoking?

Do you take any blood thinners/antiplatelets/anticoagulants

YesNo

Blood thinning medications

Have you ever had any surgery?

YesNo

Do you have any skin disorders?

YesNo

Skin disorders

Do you have any history of keloid or hypertrophic scarring?

YesNo

Procedures

Privacy

Patient Consent

Dr Azzopardi/AZZXPARDI take your privacy very seriously and strive to keep any information provided strictly confidential and safe. Information that you provide is used to improve your healthcare journey.

We are guided by The Privacy Act 1988 which regulates how private sector health service providers handle your information. The Privacy Amendment Act 2012 (Enhancing Privacy Protection) outlines 13 principles by which we are bound.

The primary purpose of collecting your personal information and medical history is to optimise the treatment that we provide for you and to deliver it in the safest way possible.

Information gathered also assists us to continue to improve and manage our practice as well as to carry out audits and accreditation processes.

Photography Consent

Photographs are taken routinely as part of the treatment journey. This includes pre operative, intra operative and post operative photographs and/or videos. Signing this form provides consent for photographs and/or videos to be taken and be part of your confidential medical records.

The following questions ask you for your permission to share your photographs and/or videos for specific circumstances. Photographs and/or videos help other patients make informed decisions and also play an important role in teaching upcoming surgeons.

Would you like to consent for you photographs and/or videos to be used for:

Patient pre operative journey through before and after images?

YesNo

Teaching other health professionals and surgical trainees?

YesNo

Publications in medical journals?

YesNo

Social media such as Instagram and Facebook

YesNo

Fees and Medicare

Initial consultation fee is $285 for a cosmetic presentation and an out of pocket gap of $180 for a medically indicated presentation.

Medicare will not cover a consultation for cosmetic surgery or a cosmetic procedure.

Some procedures such as an upper eyelid blepharoplasty or septoplasty may have a Medicare rebate in very specific circumstances.

As per AHPRA, cosmetic surgery presentations require a referral from a GP or other specialist before being seen by a plastic surgeon. Non cosmetic medically indicated presentations also require a referral letter before being seen.

Patient Signature *

Clear