ARPS - Patient History Form

Welcome to AR Plastic Surgery patient forms. Please complete all applicable fields and submit this form prior to your appointment. In accordance with the Privacy Act (1988) all information collected in this practice is treated as ‘sensitive information'. Please skip to the next question if the item is not applicable to you. You may review our privacy policy here and payment/refund policy here. Please note that for security reasons any information entered into this form will be removed if the form is not submitted within 30mins of loading this page. If this occurs the form will need to be completed again.

Before starting your form please ensure you have the following information available:

Contact details
Medicare and Health fund cards
Medications, results or photos for uploading near the end of the form

Please choose Appointment Type* This field is required.Skin Lesions eg removal of skin cancer, cysts, lipoma Medical and cosmetic eg. breast surgery, body surgery and facial surgery

Skin Lesions

Medical & Cosmetic Procedures

Name* This field is required.

Title

First Name

Last Name

Other Given Names

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Date of Birth:* This field is required.

Date

Please select gender* This field is required.

Occupation (Used for recovery advice):* This field is required.

Contact details* This field is required.

Contact number

Preferred contact

Mobile

Home

Work

Mobile

Home

Work

Contact number

Preferred contact

Contact number

Preferred contact

Contact number

Preferred contact

Email address:

example@example.com

I authorise the practice to communicate via phone, email and message when necessary. This may include marketing information about AR Plastic Surgery.* This field is required.Deselect option if required.

SMS Message

Preferred Phone Number

Marketing

Medicare and Private Health

Medicare Number:* This field is required.

Ref No (in front of name):* This field is required.

Exp Date:* This field is required.

MM/YYYY

If you are considering medically necessary surgery, we encourage you to contact your private health fund prior to your appointment and ask them to send you a copy of your private health information statement (PHIS). This will provide helpful information about your level of coverage. Please continue this form.

Please select your private health fund from the list below:* This field is required.If you do not have a private health fund please select 'uninsured'.

Membership No:Usually a longer number written on the back of the card

List the reference number beside your nameUsually 1,2,3,4,5 etc.

Health Fund Policy Tier:* This field is required.Please refer to your Private Health Information Statement emailed or sent each year on your renewal date. This information is very important should you need a private hospital admission for day or overnight hospital stay. Tip: bring this with you to your appointment.

Self Insured (no private health)

Gold

Silver

Bronze

Unsure

Other

DVA CardPlease select card if applicable or move on to the next question

Gold

White

Orange

DVA Card No. Provide the number of your DVA card.

Concession card numberIf applicable please provide concession card if you have one and the number (this may apply to pharmacy and blood tests)

Regular GP and Clinic Name

Referring Doctor or Specialist* This field is required.If same please indicate same.

How Did You Hear About Us?* This field is required.Please tick all that apply

Friends/relatives

Facebook/Instagram

Website

Google

Dr Eddie Cheng/ARPS

Online support group

Specialist

Wesley Hospital

Westside Private

Real Self

Health Engine

Previous Peter Catt patient

Other

Please share the Friend/relative who suggested us?Optional

Please let us know which Forums have been useful to you if any?eg. Facebook groups etc.

Emergency Contact Details:* This field is required.Please type full name, contact phone number.

Relationship:* This field is required.Emergency contact relationship

Health History

Current Height (cm)* This field is required.Required to calculate Body Mass Index

Current Weight (kg)* This field is required.Required to calculate Body Mass Index

For weight loss patients please indicate your heaviest weight (kg) and approximate month/yearThis will assist assessment with medicare criteria in relation to significant weight loss.

Eg. 100kg May 2019

Do you have any Allergies?* This field is required.

Yes

Other

Please list each allergy and describe their associated reaction (both drug and non-drug-related allergies)

Do you have any of the medical conditions? Please select the box if yes.* This field is required.Please select all that apply

Not applicable

Anaesthetic Problems

Angina

Anxiety or depression

Arthritis

Artifical heart valve/implant/defibrillator pacemaker/cardiac stent

Artificial Heart Valve

Artificial Joints

Asthma/bronchitis/emphysema

Blood disorders, bleeding, bruising, anaemia

Bloods Clots

Cancer

Cancer treatments eg. chemo, XRT, immunotherapy)

Cold Sores

Currently or possibly pregnant

Deep Vein Thrombosis

Diabetes

Emphysema

Epilepsy/fits/seizures

Haemophilia

Healing Problems

Heart Attack/Angina/Chest Pain

Heart disease/irregular heartbeat/murmur

Hepatitis C

High Blood Pressure

HIV/AIDS Positive

Keloid Scars

Kidney disease

Kidney Problems

Liver disease

Neurological conditions (eg Parkinsons, MS, Guillain Barre syndrome)

Pacemaker

Pain issues

Pregnancy

Psychiatric/Psychological

Psychological disorders

Radiation Therapy

Sleep apnoea

Sleeping difficulties

Spinal/Neck Problems

Stroke/TIA

Thyroid condition

If you have a condition not listed above or need to add further details please describe:

Please list major / relevant surgical history:

Please let us know if you have contracted Covid19 recently?If you have recently been infected with Covid 19 this may effect your abilty to receive anaesthetic.

Please list current medications including prescription, over the counter or herbal supplements. Please take special care to list any blood thinners such as Aspirin, Warfarin, GPL-1 weight loss drugs (e.g. Ozempic), and Fish Oil or upload your medication list by clicking the next button and uploading the file.* This field is required.

For breast surgery patients - have you ever had a mammogram and or an Ultrasound Scan?* This field is required.

Yes

Please enter approximate date/yearMM/YYYY of scan

For all breast and body surgery please add number of children and current agesThis is required for medicare criteria

Example: 3 children (9,6,2)

Please upload mammogram report here, if available

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Smoking habits - please include vaping, tabacco products, cannabis products including medicinal cannabis. Please choose the most appropriate* This field is required.

Never

Current user

In the past

Describe the product and frequency of useEg. Vaping 4 x daily.

If you quit in the last 5 years, please tell us when?

Alcohol - Please choose the most appropriate* This field is required.

Non Drinker

1-2 glasses/week

3-4 glasses/week

5+ week

Other

In your own words tell us your key points of concern

Breast implant patients, please indicate the previous date of surgery, implant brand and size and upload implant card details if available in the upload file area.This question applies to patients who currently have breast implants

Please upload any medication lists, histology, results, photo's, scans or reports here, if available

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

What Concerns would you like to discuss with your surgeon? In your own words, tell us the main reason why you want to have this surgery.This questions must be completed for cosmetic surgery patients.

What results are you hoping to achieve after surgery? (Please email ideal photos/results)This questions must be completed for cosmetic surgery patients.

Has another doctor or surgeon ever declined to undertake cosmetic surgery for you?* This field is required.This questions applies to any patient considering cosmetic surgery.

Has another doctor or surgeon ever declined to undertake cosmetic surgery for you?* This field is required.This questions must be completed for cosmetic surgery patients.

Yes

Not applicable

Do you have a preference for the timing of your surgery?Keep in mind that recovery for larger procedures other than skin cancer will need a minimum of 6 weeks to resume normal activities.

Will you have a support person to assist you with your recovery?* This field is required.

Do you have any special future events or holidays planned?* This field is required.(i) Important for recovery advice

Yes

Do you have any other concerns?Non surgical treatment options concerns may be discussed with your treatment coordinator.

Poor skin texture

Smile/frown lines

Thin lips

Skincare

Other

I give permission to AR Plastic Surgery, its agents and advisors to contact me via SMS, mobile and email regarding appointment details, recalls, notifications and marketing* This field is required.

Yes

I give my consent to AR Plastic Surgery, its agents and advisors:* This field is required.Please deselect individual options if you do not consent.

I give my consent to AR Plastic Surgery, its agents and advisors, to contact medical practitioners or other bodies I have consulted with, to obtain health and other information that mat be pertinent to my care.

I give my consent to AR Plastic Surgery, its agents and advisors, to disclose any relevant health information relating to any upcoming surgery/ies to treating clinicians and hospitals as required

I understand that unless I advise otherwise, AR Plastic Surgery will continue to liaise with the medical practitioners nominated above on matters related to my ongoing care.

I understand that my Specialists and AR Plastic Surgery and may use Heidi Health automated transcription and summation of my consultation.

I agree to the use of phone, email and SMS for correspondence relating to AR Plastic Surgery including marketing material. I understand i can unsubscribe at any time

Policy Acknowledgment* This field is required.Privacy agreement: We are committed to protecting the privacy of patient information and to handling your personal information in a responsible manner in accordance with the Privacy Act 1988, the Privacy Amendment (Enhancing Privacy Protection) Act 2012, the Australian Privacy Principles. You may review our Privacy Policy online or request a copy directly from our Practice Manager. Payment policy: I understand that my consultation fee and any biopsies are payable on the day of service. Estimates and details for surgical procedures will be provided to you following your consultation. You can read our payment policy here.

I have read and understand the Privacy agreement and Payment policy agreement

Other

Submitting

By submitting this form you agree to AR Plastic Surgery's payment policy, privacy policy?

Payment Policy - https://www.arplasticsurgery.com.au/patient-centre/practice-payment-policy

Signature* This field is required.By signing this form you agree that the information is true and correct at the time of completion.

Clear

Thank you for taking the time to complete this form. We are looking forward to meeting you soon. The AR Plastic Surgery Team

Date* This field is required.

Date

Hour

Minutes

ARPS - Patient History Form