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Personal Details
Title
First Name
Last Name
Preferred Name
Occupation
Date of Birth
Contact Details
Address
Suburb
State
Postcode
Phone Number
Mobile Phone
Email Address
Preferred Contact Method
Memberships
Medicare Number

Medicare IRN
Medicare Expiry (MM/YY)

Private Health Fund Name
Private Health Fund Membership Number

Are you a member of the Department of Veterans Affairs (DVA)?
YesNo


Department of Veterans Affairs (DVA) Member Number
DVA Card Level

Do you require DVA transport booked for you?
YesNo

Emergency contact
Partner Name
Partner Phone
Next of kin Name
Next of kin Phone
Relationship to next of kin
Medical Information
Referring Doctor Name
Referring Doctor Phone

Medical History
Yes – I do have relevant medical history, detailed belowNo – I do not have relevant medical history

Existing, diagnosed conditions
Previous operations
Current Medications
Current Vitamins or Dietary Supplements
Allergic reactions
Specialist details
If there are any other specialists that require clinical information, please fill the information below.

Specialist Name
Speciality
Specialist Medical Practice Name
Specialist Phone

Consent to release medical information
I give my consent to Total Upper GI Surgery, or their agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Total Upper GI Surgery, or their agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. For more information view our Patient Information Privacy Statement on this website.



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Call us on 07 3350 2533

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Total Upper GI Surgery is a team of Upper Gastrointestinal & Bariatric Specialists who provide their patients with leading expert care in the fields of Weight loss Reflux, Oesophago-gastric cancer and General Surgery.
With a focus on collaboration, Dr Rob Finch, Dr David Mitchell and Dr Kevin Chan are the specialist general surgeons providing high quality care to patients across Brisbane and greater Queensland.

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St Vincent’s Private Hospital Northside
Level 1 St Vincent’s Northside Education Centre
627 Rode Road, Chermside QLD 4032
Ph: (07) 3350 2533
Fax: (07) 3350 2511
Email: [email protected]

Copyright Total Upper GI Surgery 2019. All rights reserved.