Patient Registration & Consent

Patient Information

First Name(Required)

Surname (as per Medicare card)(Required)

Date of Birth(Required)

How did you hear about us?(Required)

GP/Specialist Referral

Friend/Family

GYON Website

Social Media

Other

Address(Required)

Street Address City State Postcode

Telephone - Mobile(Required)

Telephone - Home

Telephone - Work

Email(Required)

By providing your email you are agreeing to receive correspondence regarding your medical care.

Employment

Emergency Contact

Emergency Contact Name(Required)

Emergency Contact Mobile Number(Required)

Emergency Contact Relationship(Required)

Partners Name

Partners Occupation

Referring Doctor Details

Referring Doctor Name(Required)

Referring Doctor Address

Street Address City State Postcode

GP's Name(Required)

Clinic Name

GP Address

Street Address City State Postcode

Medicare / Health Fund

Medicare No.(Required)

Ref No. (Number next to your name on the card)(Required)

Expiry Date(Required)

Private Health Fund

Membership No.

If uninsured

Please Select

Health Care Card/Pension No.

Dept of Veterans Affairs No.

Patient Medical History

Country of Birth(Required)

Allergies(Required)

Weight (kg)(Required)

Height (cm)(Required)

Anticoagulant Medications History

Prior to your surgery, it is extremely important that we are aware of any medication that you may be on to thin out your blood. To help us gather this information, please answer the following questions.

Do you take any of the following medications?

Aspirin(Required)

Yes

You may know it as: Aspro Clear, Cardiprin, Solprin, DBL Aspirin, Astrix, Ecotrin , Cartia, Disprin

Warfarin(Required)

Yes

You may know it as: Coumadin, Marevan

Asasantin SR(Required)

Yes

You may know it as: Aspirin, Dipyridamole

Iscover or Plavix(Required)

Yes

You may know it as: Clopidogrel hydrogen sulphate

Persantin or Persantin SR(Required)

Yes

You may know it as: Dipyridamole

Xarelto(Required)

Yes

You may know it as: Rivaroxaban

Eliquis(Required)

Yes

You may know it as: Apixaban

Pradaxa(Required)

Yes

You may know it as: Dabigatin

Ticlid, Ticlopidine Hexal, Tilodene(Required)

Yes

You may know it as: Ticlopidine hydrochloride

Any other blood thinning medication(Required)

Yes

You may know it as: Fragmin, Dalteparin sodium, Clexane, Enoxaparin sodium, Heparin

Fish Oil products(Required)

Yes

You may know it as: Omega 3

Have you had any recent scans or pathology done in relation to the purpose of your appointment today?

Recent Pathology?(Required)

Yes

What company were they collected from?

i.e. SNP, QML, Mater Pathology

Recent Scans?(Required)

Yes

Where were the scans done?

i.e. QScan, QueenslandXRay, Savage Xray

COVID Exposure

Have you previously had COVID?(Required)

Yes

When did you have COVID?

QCGC Privacy Consent

The provision of quality health care requires a doctor-patient relationship of trust and confidentiality. Consistent with our commitment to quality care this practice has developed a policy to protect patient privacy in compliance with recent legislation.

It is necessary for us to collect personal information from patients and sometimes others associated with their health care in order to attend to their needs and for administrative purposes. In the interests of the highest quality and continuity of the patient’s health care this may also include sharing information with other health care providers who comprise a patient’s medical team from time to time.

Research is regularly carried out by medical specialists to assist in developing better treatment/cures for diseases. As a current full member of the Queensland Gynaecological Cancer QAC, as a consenting patient, data will be stored and processed relating to your condition/treatment for research and education purposes (note: patient identity will be withheld from any reports or publications), in addition, patient data will be reviewed regarding treatment outcomes in quality assurance programs at QCGC, to self-audit and further improve surgical performance.

Do you consent to Queensland Centre for Gynaecological Cancer (QCGC) storing your patient data for the purpose of research, education and to be reviewed in quality assurance programs to further improve patient outcomes?

QCGC Consent(Required)

Yes

Gynaecological Examination Consent

As part of your care a gynaecological examination will generally be performed by your doctor. The precise nature of this examination will be discussed with you prior. Please advise the practice if you would prefer to have a support person present. It is important that you communicate with your doctor if you feel uncomfortable at any point during this examination, either from physical discomfort or modesty discomfort.

Would you like to bring a support person for the examination?(Required)

Yes

Do you agree to a gynaecological examination?(Required)

Yes

Would you like us to provide a support person for the examination?(Required)

Yes

As part of the process of quality assurance, there is a weekly Clinico-Pathological meeting involving gynaecologic oncologists, radiation oncologists, medical oncologists and pathologists. At this meeting clinical information is presented on all patients treated for gynaecological cancer over the preceding week. Personal details are removed to ensure anonymity. The advantage of this meeting is the highest standards of peer review and the opportunity of multiple experienced opinions on each case of gynaecological malignancy. In some circumstances, a fully rebateable charge will be made for this multidisciplinary meeting – Medicare will be billed directly with no out of pocket expense for the patient.

This practice will also send a letter to all relevant health care providers detailing the treatment provided.

It is necessary for the staff to record your current height and weight measurements in order to calculate your BMI for research and clinical purposes.

Your consent(Required)

I have read the above information and give my consent.

Patient Registration & Consent Form

Please complete the following Patient Registration & Consent Form when requested by our team.

Patient Information

Emergency Contact

Referring Doctor Details

Medicare / Health Fund

If uninsured

Patient Medical History

Anticoagulant Medications History

Do you take any of the following medications?

Have you had any recent scans or pathology done in relation to the purpose of your appointment today?

COVID Exposure

QCGC Privacy Consent

Gynaecological Examination Consent

From the very first consultation through to personalised treatment and beyond, you’ll be expertly cared for by an exceptional team.