• GME Theatre Admission Form

    GME Theatre Admission Form

  • Form must be returned at least 10 business days prior to admission.

  • PATIENT ADMISSION DETAILS

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  • PATIENT DETAILS

    Please document as your name appears on your Medicare Card

  • Format: 0000-000-000.
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  • FINANCIAL DETAILS

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  • Format: 0000-000-000.
  • Format: 0000-000-000.
  • Format: 0000-000-000.

  • OFFICE USE ONLY

  • PATIENT PRE-ADMISSION HISTORY

  • YOUR PHYSICAL HEALTH & MEDICAL HISTORY

  • Rows

  • HEALTH & RISK ASSESSMENT

  • Rows

  • INFECTION CONTROL RISK ASSESSMENT

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  • SURGICAL HISTORY

  • ANAESTHETIC HISTORY

  • MEDICATIONS

  • PATIENT DECLARATION

  • I certify that I have a responsible adult who will accompany me home after my procedure and stay with me overnight. I understand that my procedure may be cancelled if these arrangements are not confirmed and in place prior to my admission for my procedure. I understand the importance and agree to follow instructions regarding my post-operative care. I undertake not to drive, operate machinery, drink alcohol, sign legal documents or make significant decisions following my anaesthetic until the next day or advised by my doctor.

  • OFFICE USE ONLY

  • Rows
  • Rows
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  • Clear

  • Click submit to record your responses.

  • Should be Empty: