First Name *

Last name *

Address *

City *

State *

Post Code *

E-Mail *

Date of Birth *

First Name *

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 HistoryNo 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. *