Patient Information Form

To assist us with your consultation please complete the following online form prior to your appointment.

Alternatively you can download a PDF of the form to complete manually.

Title

First Name

Surname

Address

Suburb

State

Postcode

Date of Birth

Phone H/W

Mobile

I DO NOT want to receive SMS reminders for my appointment

Next of Kin

Relationship

Phone

Usual Doctor

Usual Doctor’s Practice

Medicare Card Number

Reference No.

Expiry Date

Private Health Insurance

Name of Health Fund

Policy No.

Type of Cover

Do you have a DVA Card?

Is this a Work Cover Claim? (if yes, please notify reception)

How did you hear about us?

Other, please specify

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

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).

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.

I hereby consent to my personal information being released as and when required

Are you ready to find out more?

Call us today for a complimentary 30-minute consultation with our Bariatric Nurse Educator or one of our Bariatric coordinators.