Fill out our patient details form online below

Or Download our patient details form in pdf format here

    Personal Details

    Date of birth*

    Next of Kin

    Date of birth (if parent)

    Referrer Details

    Medicare / Health Fund Details / DVA (Veterans Affairs)

    Membership over 12 months

    Fund excess

    Type

    Health Questions

    Could you be pregnant?

    Do you use Contraceptives?

    Do you smoke?

    In the past 6 months, have you had the following?:

    If you selected that you did have a specialist appointment in the last 6 months, please tell us the reason:

    Have you had any previous surgery?

    Do you have any Prostheses? (joint replacements/implants)

    Have you had Cardiac Stenting / Valve or Bypass Surgery?

    Do you have a Pacemaker?*

    Are you on blood thinning medication?*

    If yes, did a GP or Specialist prescribe it?

    Do you take Cortisone Tablets / Injections or Anti-inflammatory Drugs?*

    Do you have Hypertension?*

    Do you have Diabetes?*

    If so, which type?

    Do you have Thyroid issues?*

    Do you have any Allergies?* (Food/Medication/Tapes/Non-prescription drugs)

    Have you had Covid Vaccinations?*

    Have you been infected with Covid in the past 4 – 6 weeks?*

    If yes, on what date date?

    Are you aware you must have someone to stay with you for 24hrs following surgery?*

    Are you aware that you are not allowed to drive for at least 24 hours?*

    Consent

    RECORDING OF CONSULTATIONS

    As part of your visit with us Dr Arianayagam will record his consultation. This is then stored in your consultation notes as
    an MP3 file.

    I agree to my consultation being recorded*

    PHYSICAL EXAMINATION

    If you are consulting with Dr Arianayagam regarding any part of your body that is covered by clothing, you may be asked
    to undress. For your privacy, you will offered a dignity sheet to use during the examination. Dr Arianayagam will ask that one of his staff accompany him during the examination, for both your protection as well as his own. Pre-operative photo’s may also be taken during this examination.

    * I consent to an examination being undertaken, which may involve partial or full removal of my clothing.
    * I consent to pre-operative photographs being taken, which may involve partial or full removal of my clothing

    Dr Arianayagam records his consultations to assist with record keeping. Your signature below confirms your consent and that all information provided on this form is correct. If you have any concerns, please speak with the reception staff.

    Please type your full name below as well as sign

    Print your name here:
    Sign your name here:

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