1 Online ADMISSION (preferred). 1 Access the website of your nominated hospital: 01A. City East PATIENT ADMISSION form . North Shore City West At least 7 2 Go to the Pre ADMISSION section days before & select 01A PATIENT ADMISSION form . City East | North Shore | City West ADMISSION 3 Complete and SAVE it to your device 4 Attach your completed form to an email and send to PATIENT label the admin' email address above of your nominated hospital Planned ADMISSION date OR Paper ADMISSION Complete and send to Reception at your nominated Hospital. PATIENT details TITLE GIVEN NAMES FAMILY NAME. ADDRESS POSTCODE. POSTAL ADDRESS. (IF DIFFERENT TO ABOVE) POSTCODE. TEL HOME TEL WORK MOBILE.
2 EMAIL ADDRESS please print clearly PERMANENT. DATE OF BIRTH / / SEX FEMALE MALE RESIDENT YES NO. MARITAL STATUS M S D W SEP DE FACTO. INDIGENEOUS ABORIGINAL T ORRES STRAIT ISLANDER BOTH NEITHER. LANGUAGE. COUNTRY OF BIRTH OCCUPATION. SPOKEN AT HOME. MEDICARE NO. REFERENCE NO. LOCATED BESIDE YOUR. NAME ON YOUR CARD. EXPIRY DATE. Emergency contacts TEL. NEXT OF KIN RELATIONSHIP. MOBILE. TEL. NAME OF ESCORT RELATIONSHIP. MOBILE. Your Health Fund NAME OF FUND MEMBERSHIP NO. I HAVE NO HEALTH FUND COVER. WRITTEN APPROVAL FOR DAY SURGERY PROCEDURE MUST BE RECEIVED BY THE FACILITY PRIOR TO ADMISSION . I HAVE OVERSEAS INSURANCE OR FULL PAYMENT WILL BE REQUIRED ON ADMISSION . HAVE YOU BEEN ADMITTED TO HOSPITAL IN THE LAST 28 DAYS?
3 YES. NO. Pension & health care card details (if applicable). PENSION NO. EXPIRY DATE. DVA CARD COLOUR. DEPT VETERANS AFFAIRS NO. SUBURB OF. REFERRING LOCAL DOCTOR LOCAL DOCTOR. If claiming workers compensation/third party accident insurance WRITTEN APPROVAL FOR DAY SURGERY PROCEDURE MUST BE RECEIVED BY THE FACILITY PRIOR TO ADMISSION OR FULL PAYMENT WILL BE REQUIRED ON ADMISSION . EMPLOYER. ADDRESS POSTCODE. TEL. CONTACT DATE OF ACCIDENT / /. INSURANCE COMPANY. CONTACT CLAIM NO. ADDRESS POSTCODE TEL. SDH-FM-001A. VERSION 7. IST ISSUE APPROVAL GIVEN YES NO (IF YES, PLEASE ATTACH CONFIRMATION LETTER). 17 OCT12. Payment agreement REVISED 5 SEPT16. To the best of my knowledge, the above information is true and correct.
4 I agree to pay any shortfall in reimbursement by the Health Fund. PATIENT SIGNATURE DATE. PLACE BARCODE LABEL HERE. Risk assessment MEDICAL HISTORY. List previous operations, hospital admissions or any major/serious illness DO YOU HAVE, NOW OR IN THE PAST, ANY OF THE FOLLOWING? YES NO. CIRCULATION. SEVERE HEART PROBLEMS. Heart attack, heart failure, acute myocardial infarction. Any recent hospitalisation for heart disease A PACEMAKER OR DEFIBRILLATOR. Please bring your Pacemaker/Defibrillator card with you BLOOD CLOTS (DVT/PE). STROKE (TIA). Malignancy or recent fracture Blood pressure NORMAL HIGH LOW . Anaemia SEVERE LUNG DISEASE. RESPIRATORY. Asthma Have you experienced an adverse reaction during anaesthesia Recent respiratory infection (cold or flu) or signs or symptoms with a temperature over 38 degrees?
5 If YES, please contact general or local? YES NO the Clinical Services Manager at your nominated hospital. Has any of your family experienced an adverse event during anaesthesia? Sleep apnoea SYSTEMS. YES NO If YES, please specify Vision impairment Hearing impairment Cochlear implant Bladder / kidney problems Anxiety / depression / panic attack Epilepsy / seizures / fits / dizzy spells INFECTION. Tick if any apply to you Hepatitis A B C D E . Tick if any apply to you TB MRSA VRE CRE . MEDICATIONS / ALLERGIES. Please list current medications including any non-prescribed medications In the last 2 weeks, have you had, or been in contact with, such as vitamins, herbs, natural or traditional therapies anyone with Chicken Pox or German Measles?
6 Do you or any of your family suffer from or had exposure to MEDICATION/DRUG OR VITAMIN HOW Creutzfeldt jakob disease (CJD)? NAME STRENGTH NO. TAKEN. OFTEN Received human pituitary hormone or had a dura mater graft between 1972 and 1989? DENTAL MOBILITY. Crowns, bridges, dentures, caps Dental problems (eg gum disease, loose teeth, cracks). Fallen in the past 12 months Medication in the past 24 hours that impairs your co-ordination/. mental function Cognitive impairment (eg disorientation, dizziness, confusion, memory loss, inability to follow instructions). Have you used steroid/cortisone medication in the past 6 months? Back pain or injury / mobility problems YES NO Bed or wheel chair bound SKIN.
7 BLOOD Have you taken any blood thinning medication this week? Skin rash, eczema, skin tear THINNERS eg Aspirin, Warfarin, Coumadin, Clopidogrel, Iscover, Plavix, History of pressure areas Brufen, Nurofen, Indocid) or Natural Thinners (eg Vitamin E, LIFESTYLE. Alcohol: How much each day? _____ Standard drinks Chinese herbs, Ginkgo, Fish Oil)? YES NO . DIABETES D. o you use insulin YES NO Tobacco: How many each day? _____. Are you tablet controlled ? YES NO . Are you diet controlled? YES NO Have you ever used IV or recreational drugs? OTHER. Please bring ALL diabetic tablet medications AS WELL as your If female, are you pregnant? INSULIN on day of ADMISSION . Needle phobia: ALLERGIES Do you have any known allergies to any medications, dressings, If YES, please inform reception staff upon arrival latex or food?
8 If yes, please list Any medical conditions/physical disability that may affect your procedure with us? If YES, please list HEIGHT in cms _____ WEIGHT in kgs _____. PATIENT /GUARDIAN SIGNATURE DATE. ADMISSION NURSE If YES to any of the above, record in COMMENTS section of Theatre Checklist NURSE SIGNATURE DATE. PATIENT label Privacy information statement In order to provide your medical treatment, the Day Hospital will need to collect Sending of specimens for analysis;. and use personal information about you. The information we may need to Account keeping and billing, including Medicare and private health insurance collect and how it will be used, including possible disclosure to third parties and claims.
9 Rights you have in relation to that information is explained in this statement. We The management of our practice, including quality assurance and practice appreciate the sensitivity of personal health information and undertake to keep accreditation;. your information confidential and use it only as outlined below. Complaints handling and notification to our insurers;. 1. Collection Disclosure to third parties, including the Director General of the NSW Ministry of Health, where legally required to do so, such as producing documents The Day Hospital and its medical practitioners and staff will collect the in answer to a court subpoena or mandatory reporting of certain notifiable information that is necessary for us to provide advice and treatment to you.
10 Diseases. This information may include: your medical history; In addition, we may use non-identifying information taken from your medical file your family medical history; for data analysis and research. your symptoms, diagnosis and recommended treatment; 3. Access ethnicity; Except in a very limited range of circumstances recognised under relevant privacy contact details; legislation, you are entitled to access your own health records at any time Medicare/private health fund details; and convenient to both yourself and the practice. Your request should be forwarded in billing/account details. writing. A fee will be charged for staff time in retrieving files and photocopying to The information will normally be collected directly from you.