Haematology Queensland | HQ Clinic Brisbane - Patient Admission Information

PATIENT DETAILS...

Title

Sex

Male
Female

Marital Status

Surname

Given Names

Residential Address

Street Address Post Code

Postal Address

Street Address Post Code

Email Address

Phone: Home

Work

Mobile

I consent to receive SMS reminders for my upcoming appointments

Yes
No

Date of Birth

Country of Birth

Are you of Aboriginal or Torres Strait Islander Origin?

Yes
No

Occupation

NEXT of KIN...

Title

Relationship

Name

Address

Phone: Home

Work

Mobile

Name of REFERRING DOCTOR...

Name of referring doctor

Name of GENERAL PRACTITIONER (GP)...

Name of GP

Do you have an ENDURING POWER of ATTORNEY?...

You would use an Enduring Power of Attorney to appoint someone to make financial and / or personal decisions on your behalf if you became unable to make your own decisions.

No
Yes

If yes, ...please consider providing a copy for our record

Do you have an ADVANCED HEALTH DIRECTIVE?...

An Advance Health Directive is a document that states your wishes or directions regarding your future health care for various medical conditions. It comes into effect ONLY if you are unable to make your own decisions.

No
Yes

If yes, ...please consider providing a copy for our record

ENTITLEMENTS / HEALTH COVER DETAILS...

MEDICARE NUMBER

Number NEXT to your name on the Medicare card

EXPIRY DATE

CONCESSION CARD NUMBER

EXPIRY DATE

PHARMACEUTICAL SAFETY NET NUMBER

YEAR OF ISSUE

DVA NUMBER

(Department of Veterans’ Affairs)

Color of Card

Gold
White
Orange

Do you have PRIVATE HOSPITAL INSURANCE?

Yes
No

If yes, please complete the following

NAME OF FUND

MEMBERSHIP NUMBER

COMPLETED BY...

Thank-you for your time. When you have your consultation, please let me know if you have any questions about this form.

Name

First Last

Signature

Date