IB Bari General Patient Info and HQ Form

IB Bari General patient info and HQ

Your Privacy, Our Concern – Consent to use your personal information

The information we have requested from you is very important for us to provide you with the best possible care and
outcome.

Dr Ian Baxter and The Sunshine Coast Medical Weight Loss Centre complies with the
Commonwealth Privacy Act and all other state and territory legislative requirements in relation to
the management of personal information. We collect information that is necessary for the provision
of your health care. Personal information obtained from you in your consultation may be used to
provide information to various health services involved in supporting your health care management
(e.g. pathology, radiology, hospitals or other specialists). We may contact you up to four times a year
by email to obtain statistical information for the Bariatric Surgery Register, patient support group
meetings and other health related information. Our website captures information for appointments,
and we may contact you by phone or email. Our Privacy and appointment cancellation policy is
available to view at reception or upon request. Your My Health Record will be accessed and your
information uploaded online to your records.
If the patient lacks capacity to consent, a guardian may sign on their behalf, with additional risk
considerations. Please contact us if this situation arises. By signing, you affirm that the provided
information is true and correct as of the date of completion. I have read and understood the Privacy
Policy and understand my rights and responsibilities

Signature of Patient/Guardian/Power of Attorney

Guardian/Power of Attorney

Do you smoke or vape?

If yes, how many per day?

Do you drink alcohol?

How many glasses a day/week?

Medical Conditions


Do you have or have ever had the following conditions?

Cancer

Heart Murmur/Heart Disease/Heart Attack/Palpitations/Angina

Pacemaker or other Heart implant

Epilepsy/fits/faints

Diabetes Diet/Tabs/Insulin Stomach

Problems with Gastric Ulcer /Ingestion/Reflux

Hepatitis

History of Blood Clots DVT/PE

Kidney Problems

Lung Disease

Allergies, please list any

Any complications with previous Surgery?

Anaesthetic?

Medical History

Operations, please include date if known

Current Medications (please list)

Medical Allergies (please list)

Weight

kg

Height

cm

Sign Here

Patient/Guardian/Power of Attorney

Guardian/Power of Attorney