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Patient Registration

- Confidential Registration
- Title:*
- Surname:*
- First Name:*
- Date of Birth:*
  Date Format: DD slash MM slash YYYY
- Address:*
- Suburb:*
- State:*
- Postcode:*
- Telephone:*
- Email:*
- Occupation:*
- Family Doctor:*
- Family Doctor Telephone:*
- Practice Name:*
- Address:*
- Suburb:*
- State:*
- Postcode:*
- Referring Doctor:*
- Practice Name:*
- Referring Doctor Telephone:*
- Address:*
- Suburb:*
- State:*
- Postcode:*
- Medicare No:*
- No. on card:*
- Expiry:*
- Insurer Name
- Claim No:
- Health Fund:
- Member No:
- Veterans Affairs No:
- How did you hear about us:*
  - Friend/Family
  - Advertising (list)
  - Flyer
  - Referring Doctor
  - Hospital
  - Google/Internet Search
  - Website
  - Costhetics
  - Facebook
  - Other (list)
- Do you have or have had any of the following:
  - Anaesthetic problems
  - Arthritis
  - Asthma
  - Bad scars
  - Bleeding problems
  - Blood Clots
  - Cold sores
  - Diabetes
  - Healing problems
  - Hepatitis
  - High blood pressure
  - HIV/AIDS risk
  - Psychiatric treatment
  - Spinal/neck problems
- List current illnesses:
- List current medications:
  Nb. Include - aspirin, cortisone/steroids, anti-inflammatory, warfarin, herbal products & over-the-counter preparations.
- Do you smoke?*
- How many per day?
- Alcohol intake per week?*
- Allergies:*
- Previous operations:*
- Are you interested in information on treatment possibilities relating to any of the following?
  (please tick the areas you are interested in)
  - Forehead lines
  - Crow’s feet
  - Brow droop
  - Frown lines
  - Dark circles under eyes
  - Neck ageing
  - Cheek Enhancement
  - Lower facial ageing (e.g. Jowls)
  - Lip ageing/thinning lips
  - Skin texture & quality
  - Excessive sweating
  - Sun damage
  - Downward turned mouth
  - Lip enhancement
  - Lip lines
  - Smile lines
- Patient Privacy Act
  
  As a result of new privacy laws introduced by the Government, this office requires you to read this sheet regarding your personal and medical information and then sign to say you have read and agree with the statement. Your files contain the following information:
  - Personal details (name, address, date of birth, Medicare number & health details)
  - Your medical history
  - Notes made during the course of your medical consultation
  - Referrals to other Health Service Providers
  - Results and reports received from other Health Service Providers
  This information is provided by you or arises as a consequence of information provided by you. It may be necessary for us to obtain copies of reports such as x-rays, pathology and correspondence from other Medical Professionals or confer with Surgical Colleagues or your General Practitioner regarding your medical treatment. Due to changes in the Privacy Act, it has become necessary for us to obtain written consent from each patient in our practice to obtain these records. Please note: Medical records cannot be released without your consent, except when they are required under Law such as a subpoena.
- Declaration
- I understand clinical photographs may be taken*
  - Yes
  - No
- I give permission for clinical photographs to be used for medical education*
  - Yes
  - No
- I give permission for clinical photographs to be used for patient education*
  - Yes
  - No
- I give permission for these details to be used in communication with other health professionals involved with my care*
  - Yes
  - No
- I give permission for images of myself to be used on social media*
  - Yes
  - No
- I give permission for my photos to be used for advertising and/or marketing purposes*
  - Yes
  - No
- I give permission for Dr. Laniewski to contact me via post or email*
  - Yes
  - No
- I have read the Patient Privacy Policy document*
  - Yes
  - No
- Patient Name:*
- Date:*
  Date Format: DD slash MM slash YYYY
- Signature:
Comments
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Contact Dr Laniewski

If you have a question or would like to arrange a time for a confidential consultation, please enter your details below
and we will contact you shortly.

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Phone*
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BELLA VISTA

Suite A3, 24-32 Lexington Drive
Bella Vista 2153
Ph: 1300 322 337
Ph: (02) 8824 8481

ERINA – CENTRAL COAST

Suite 1.05, Platinum
4 Ilya Avenue
Erina NSW 2250
Ph: 1300 322 337

ALBURY
The Gardens, Level 6
470 Wodonga Place
Ph: 1300 322 337
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