SOUTH PERTH Pre-admission Form HOSPITAL Pre-admission Form · Pre-admission Form To confirm your booking, please complete this form and forward to Admissions, South Perth Hospital,

HOSPITALSOUTH PERTH

Pre-admission Form

To confirm your booking, please complete this form and forward to Admissions,South Perth Hospital, at least 3 days prior to your admission date.

You may choose to post, fax or telephone through this information. If faxed or phoned, please bring original papers with you on day of admission.

Where to come:

South Perth Hospital76 South Terrace,SOUTH PERTH WA 6152

Postal Address:P.O. Box 726,COMO WA 6952

Telephone: (08) 9367 0222Facsimile: (08) 9474 2541

SWAN RIVER

MILL POINT RD

LABOUCHERE RD

CANNING HWYSouthPerthHospital

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BURCH ST

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HOSPITALSOUTH PERTH

Pre-admission Form

To confirm your booking, please complete this form and forward to Admissions,South Perth Hospital, at least 3 days prior to your admission date.

You may choose to post, fax or telephone through this information.

Where to come:

A 6152

Postal Address:P.O. Box 726,COMO WA 6952

Telephone: (08) 9367 7966Facsimile: (08) 9474 2541

SWAN RIVER

MILL POINT RD

LA

BO

UC

HE

RE

RD

CANNING H

WYSouth

PerthHospital

KW

INA

NA

FR

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WA

Y

ANGELO ST

CO

OD

E S

T

SOUTH TCE

FORT

UNE

ST

CouncilOffices

BURCH ST

P

146549 Pre-Admission MR2 1 20/10/09 2:29:24 PM

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ADMISSION FORM - PATIENT TO COMPLETE

PERSONAL DETAILSMr Mrs Miss Ms Other ............................

Surname: ....................................................................................................

Given Names: ...........................................................................................

Sex: ............................. Marital Status: .................................................

Address: ......................................................................................................

.....................................................................Postcode: ..............................

Telephone Numbers: (H):............................................................(W):.......................................... Mobile: ....................................................

Date of Birth: – –

Country/State of Birth: ..........................................................................

Religion: ............................... Employment Status:...........................ARE YOU OF . . . Aboriginal Torres Strait IslanderBoth Aboriginal & Torres Strait Islander ORIGIN?

PAYMENT DETAILSDo you have private health insurance? Yes No

PLEASE NOTE UNINSURED PATIENTS ARE REQUIRED TO PAYTHE ESTIMATED FEES ON ADMISSION. – CONTACT THEHOSPITAL ON 9367 0222 TO OBTAIN AN ESTIMATION.

PERSON RESPONSIBLE FOR PAYMENT(Where different from the patient)

Name:...........................................................................................................

Address: ......................................................................................................

.....................................................................Postcode: ..............................


YOUR HOSPITAL HISTORY1. Have you been a patient at South Perth Hospital

oNseY?erofebIf YES what year? ............................................................................

2. Has your name changed since your previousoNseY?noissimda

If YES what was your previous name?...................................

3. Have you been a patient, employee or resident in ahospital in the last 12 months? Yes NoIf YES which hospital? ...................................................................

IMPORTANTIF THE HOSPITAL WAS OUTSIDE OF WA

PLEASE CONTACT SOUTH PERTH HOSPITAL IMMEDIATELY.4. Have you been a private patient in hospital within the

oNseY?syad 7 tsal5. Do you know if there is a history of Creutzfeldt Jacob

Disease (CJD) in your family? Yes No6. Have you ever had Human Pituitary Growth Hormone

or Follicle Stimulating Hormone? Yes No

NEXT OF KIN

Name:...........................................................................................................

Relationship:..............................................................................................Address: ......................................................................................................

.....................................................................Postcode: ..............................


South Perth Hospital

Your General Practitioner’s Name:...................................................Address: ......................................................................................................

.....................................................................Postcode: ..............................

Telephone Number:................................................................................

IF YOU ARE UNABLE TO POST THIS INFORMATION TO THE HOSPITAL PRIOR TO YOUR ADMISSION,PLEASE PHONE THE INFORMATION THROUGH TO OUR ADMISSIONS OFFICE ON 9367 7966

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AFFIX HOSPITAL LABEL HERE

ADMISSION DATE: ____________________________

Please Use Hospital ID Label When AvailableNRMEMANRUS

GIVEN NAMES

XES.B.O.D

DOCTORS NAME

HEALTH INSURANCE FUND DETAILSNote: If you have private health insurance please contact your fund prior toadmission to obtain information on your level of cover and any excess or co-payment that will be payable on admission.

Fund Name:...............................................................................................

Membership Number:............................................................................Table: ............................................... Date Joined: ................................

Excess: ........................................... Co-payment: ................................

Is your health insurance premium up to date?Yes No

Contributors Name: ................................................................................

OTHER INSURANCE COVERNOTE: Should your claim be rejected by the insurance company, you willbe responsible for immediate payment.Workers’ Compensation Motor VehicleDate of Accident: .....................................................................................

Claim Number: .........................................................................................

Insurance Company Name:.............................................................

Contact Number: .....................................................................................

Name:...........................................................................................................

If Workers Compensation please complete:Employers Name: .................................................................................

Address: ......................................................................................................

Contact Number: .....................................................................................

Name:...........................................................................................................

ACCOMMODATION REQUESTED (Subject to availability)

Single Room Shared Room

PLEASE NOTE• All day surgery will be accommodated in a shared room• Single room fees are higher than shared room fees. You are

encouraged to check your level of cover prior to admission.

PHARMACEUTICAL CONCESSION CARDType: .............................................................................................................

Card Number: ...........................................................................................

Expiry Date: ...............................................................................................

Medicare Number:

No on Card: Valid to: /

SOUTH PERTHHOSPITAL

PATIENT TO COMPLETE

Please tick � if you have ever had: Y N Description

Heart Condition? (e.g.: heart attack, chest pain, angina, rheumatic fever or other) ...............................................................................................................

High Blood pressure? Low Blood pressure? ...............................................................................................................

Palpitations or irregular heart beat? ...............................................................................................................

Blood disorder? (e.g.: leukaemia, anaemia or Von Willebrand’s Disease) ...............................................................................................................

Blood clots or a bleeding disorder? (e.g.: clots in legs, clots in lungs, bruise easily or other) ...............................................................................................................

Stroke / Blackouts? ...............................................................................................................

HIV Hepatitis B or Hepatitis C ...............................................................................................................

Asthma or shortness of breath? ...............................................................................................................

Have you ever been hospitalised with breathing problems? ...............................................................................................................(e.g. bronchitis, pneumonia, emphysema, tuberculosis etc?)

...............................................................................................................

Have you had a cough, cold or sore throat in the last 2 weeks? ...............................................................................................................

Gastric reflux, hiatus hernia, heartburn, indigestion, stomach ulcers or other? ...............................................................................................................

Diabetes? Do you use insulin? Y N Do you take diabetic tablets Y N

Kidney condition? (failure, dialysis, infection, stones or other) ...............................................................................................................

Organ transplant? ...............................................................................................................

Epilepsy/Fits? ...............................................................................................................

Significant neck or back injury / problems? ...............................................................................................................

Neurological disease under evaluation? ...............................................................................................................

Any other serious illness? ...............................................................................................................

Any conditions that occur in your family? (e.g.: Thalassemia, Muscular Dystrophy) ...............................................................................................................

Has your Doctor prescribed for you Prednisolone, Cortisone or other steroids? ...............................................................................................................

Do you regularly take Aspirin, Warfarin? Date / time last taken ..........................................................................

Further details:

Preferred Name: ..........................................................

Reason for Admission .............................................................................................................................................................................Current Problem ........................................................................................................................................................................................

Teeth Your own Capped Crowned Bridges Loose

Dentures? Yes No Full Partial Upper Lower

Do you smoke? No Yes No. per day ........................

Do you drink alcohol? No Yes Type ............................... Amount per day ...................... Week.........................

Is your sight? Normal Glasses Contact lenses Prosthesis

Is your hearing? Normal Hearing Aid(s)

Do you have any special dietary requirements No Yes Please specify ....................................................................

Are you currently using support services (eg: Silver Chain, etc.)? Please specify ....................................................................

Do you have someone to stay with you overnight when you leave hospital? Yes Contact Name ........................................

No Contact No..............................................

I have answered these questions to the best of my ability Checked by Nurse (Sign & Print Name)

Signature ............................................ Date ................................ Signature ......................................... Date .............................

PATIENT HEALTH HISTORY


AFFIX ID LABEL HEREPlease Use ID Label When Available

SURNAME MRN

GIVEN NAMES

D.O.B. SEX

DOCTORS NAME

SOUTH PERTHHOSPITAL

Have you ever had Human Pituitary Hormones (growth hormone and gonadotropins) before 1986?

IMPORTANT

4. Have you been a patient, employee or resident in a

hospital outside WA in last 12 months? Yes No

If YES which hospital?.................................................

h h

IF YOU ANSWER YES TO ANY OF THE QUESTIONS BELOW PLEASE CONTACT THE HOSPITAL IMMEDIATELY

3. Have you been a private patient in hospital within the last 7 days? Yes Nohh

4. Do you have a history of Creutzfeldt Jakob Disease in your family? Yes Noh h

Neurological disease under evaluation (e.g. CJD)?

’’


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ADMISSION FORM - PATIENT TO COMPLETE

PERSONAL DETAILSMr Mrs Miss Ms Other ............................

Surname: ....................................................................................................

Given Names: ...........................................................................................

Sex: ............................. Marital Status: .................................................

Address: ......................................................................................................

.....................................................................Postcode: ..............................


Date of Birth: – –

Country/State of Birth: ..........................................................................

Religion: ............................... Employment Status:...........................ARE YOU OF . . . Aboriginal Torres Strait IslanderBoth Aboriginal & Torres Strait Islander ORIGIN?

PAYMENT DETAILSDo you have private health insurance? Yes No

PLEASE NOTE UNINSURED PATIENTS ARE REQUIRED TO PAYTHE ESTIMATED FEES ON ADMISSION. – CONTACT THEHOSPITAL ON 9367 0222 TO OBTAIN AN ESTIMATION.

PERSON RESPONSIBLE FOR PAYMENT(Where different from the patient)

Name:...........................................................................................................

Address: ......................................................................................................

.....................................................................Postcode: ..............................


YOUR HOSPITAL HISTORY1. Have you been a patient at South Perth Hospital

oNseY?erofebIf YES what year? ............................................................................

2. Has your name changed since your previousoNseY?noissimda

If YES what was your previous name?...................................

3. Have you been a patient, employee or resident in ahospital in the last 12 months? Yes NoIf YES which hospital? ...................................................................

IMPORTANTIF THE HOSPITAL WAS OUTSIDE OF WA

PLEASE CONTACT SOUTH PERTH HOSPITAL IMMEDIATELY.4. Have you been a private patient in hospital within the

oNseY?syad 7 tsal5. Do you know if there is a history of Creutzfeldt Jacob

Disease (CJD) in your family? Yes No6. Have you ever had Human Pituitary Growth Hormone

or Follicle Stimulating Hormone? Yes No

NEXT OF KIN

Name:...........................................................................................................

Relationship:..............................................................................................Address: ......................................................................................................

.....................................................................Postcode: ..............................



Your General Practitioner’s Name:...................................................Address: ......................................................................................................

.....................................................................Postcode: ..............................

Telephone Number:................................................................................

IF YOU ARE UNABLE TO POST THIS INFORMATION TO THE HOSPITAL PRIOR TO YOUR ADMISSION,PLEASE PHONE THE INFORMATION THROUGH TO OUR ADMISSIONS OFFICE ON 9367 7966

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ADMISSION DATE: ____________________________


GIVEN NAMES

XES.B.O.D

DOCTORS NAME

HEALTH INSURANCE FUND DETAILSNote: If you have private health insurance please contact your fund prior toadmission to obtain information on your level of cover and any excess or co-payment that will be payable on admission.

Fund Name:...............................................................................................

Membership Number:............................................................................Table: ............................................... Date Joined: ................................

Excess: ........................................... Co-payment: ................................

Is your health insurance premium up to date?Yes No

Contributors Name: ................................................................................

OTHER INSURANCE COVERNOTE: Should your claim be rejected by the insurance company, you willbe responsible for immediate payment.Workers’ Compensation Motor VehicleDate of Accident: .....................................................................................

Claim Number: .........................................................................................

Insurance Company Name:.............................................................

Contact Number: .....................................................................................

Name:...........................................................................................................

If Workers Compensation please complete:Employers Name: .................................................................................

Address: ......................................................................................................

Contact Number: .....................................................................................

Name:...........................................................................................................

ACCOMMODATION REQUESTED (Subject to availability)

Single Room Shared Room

PLEASE NOTE• All day surgery will be accommodated in a shared room• Single room fees are higher than shared room fees. You are

encouraged to check your level of cover prior to admission.

PHARMACEUTICAL CONCESSION CARDType: .............................................................................................................

Card Number: ...........................................................................................

Expiry Date: ...............................................................................................

Medicare Number:

No on Card: Valid to: /

SOUTH PERTHHOSPITAL

PATIENT TO COMPLETE

Please tick � if you have ever had: Y N Description

Heart Condition? (e.g.: heart attack, chest pain, angina, rheumatic fever or other) ...............................................................................................................

High Blood pressure? Low Blood pressure? ...............................................................................................................

Palpitations or irregular heart beat? ...............................................................................................................

Blood disorder? (e.g.: leukaemia, anaemia or Von Willebrand’s Disease) ...............................................................................................................

Blood clots or a bleeding disorder? (e.g.: clots in legs, clots in lungs, bruise easily or other) ...............................................................................................................

Stroke / Blackouts? ...............................................................................................................

HIV Hepatitis B or Hepatitis C ...............................................................................................................

Asthma or shortness of breath? ...............................................................................................................

Have you ever been hospitalised with breathing problems? ...............................................................................................................(e.g. bronchitis, pneumonia, emphysema, tuberculosis etc?)

...............................................................................................................

Have you had a cough, cold or sore throat in the last 2 weeks? ...............................................................................................................

Gastric reflux, hiatus hernia, heartburn, indigestion, stomach ulcers or other? ...............................................................................................................

Diabetes? Do you use insulin? Y N Do you take diabetic tablets Y N

Kidney condition? (failure, dialysis, infection, stones or other) ...............................................................................................................

Organ transplant? ...............................................................................................................

Epilepsy/Fits? ...............................................................................................................

Significant neck or back injury / problems? ...............................................................................................................

Neurological disease under evaluation? ...............................................................................................................

Any other serious illness? ...............................................................................................................

Any conditions that occur in your family? (e.g.: Thalassemia, Muscular Dystrophy) ...............................................................................................................

Has your Doctor prescribed for you Prednisolone, Cortisone or other steroids? ...............................................................................................................

Do you regularly take Aspirin, Warfarin? Date / time last taken ..........................................................................

Further details:

Preferred Name: ..........................................................

Reason for Admission .............................................................................................................................................................................Current Problem ........................................................................................................................................................................................

Teeth Your own Capped Crowned Bridges Loose

Dentures? Yes No Full Partial Upper Lower

Do you smoke? No Yes No. per day ........................

Do you drink alcohol? No Yes Type ............................... Amount per day ...................... Week.........................

Is your sight? Normal Glasses Contact lenses Prosthesis

Is your hearing? Normal Hearing Aid(s)

Do you have any special dietary requirements No Yes Please specify ....................................................................

Are you currently using support services (eg: Silver Chain, etc.)? Please specify ....................................................................

Do you have someone to stay with you overnight when you leave hospital? Yes Contact Name ........................................

No Contact No..............................................

I have answered these questions to the best of my ability Checked by Nurse (Sign & Print Name)

Signature ............................................ Date ................................ Signature ......................................... Date .............................

PATIENT HEALTH HISTORY



SURNAME MRN

GIVEN NAMES

D.O.B. SEX

DOCTORS NAME

SOUTH PERTHHOSPITAL

Have you ever had Human Pituitary Hormones (growth hormone and gonadotropins) before 1986?

IMPORTANT

4. Have you been a patient, employee or resident in a

hospital outside WA in last 12 months? Yes No

If YES which hospital?.................................................

h h

IF YOU ANSWER YES TO ANY OF THE QUESTIONS BELOW PLEASE CONTACT THE HOSPITAL IMMEDIATELY

3. Have you been a private patient in hospital within the last 7 days? Yes Nohh

4. Do you have a history of Creutzfeldt Jakob Disease in your family? Yes Noh h

Neurological disease under evaluation (e.g. CJD)?

’’


PATIENT TO COMPLETE


AFFIX ID LABEL HERE

PATIENT HEALTHHISTORY

Please Use ID Label When AvailableNRMEMANRUS

GIVEN NAMES

XES.B.O.D

DOCTORS NAME

PLEASE ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR CURRENT AND PREVIOUSMEDICAL HISTORY. IF YOU REQUIRE ASSISTANCE, PLEASE SEE YOUR DOCTOR

The following question should be

Please Indicate: Your weight ________kg Height _________cm

answered by ticking the appropriate boxAny necessary details should be given in the spaces provided. If extra space is required, please add a separate sheet of paper.

Have you been hospitalised before? No Yes For what conditions? Please specify below

3. Do you take any regular medications? No Yes Please list them below:(e.g. tablets, pills, Injections, puffers, aspirin or natural therapies)

erudecorP / noitidnoCraeY

Name of Medicine and Dose Time Taken Name of Medicine and Dose Time Taken

4. Have you had a general anaesthetic in the No Yespast 3 months?

5. Does a general anaesthetic cause any unusual No Yes If Yes, please specify: .......................................reaction to you? ..............................................................................

6. Does a general anaesthetic cause any unusual No Yes If Yes, please specify: .......................................reaction in your family? ..............................................................................

Please specify relationship: ...........................................................................................................

7. Do you have any questions / concerns No Yes If Yes, please specify: ........................................about your hospital discharge? ..............................................................................

......................................................................................................................................................................................................

2. Do you have any allergies / unusual reactions? No Yes What are they? What reaction did you have?(especially to medicines, sticking plaster or food)

......................................................................................................................................................................................................

......................................................................................................................................................................................................

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CONSENT TO USEINFORMATION

We acknowledge our obligations to you under the Privacy Amendment (Private Sector) Act 2000.

Personal information we collect from you will be used primarily to ensure that you receive optimalcare, but may also be used for other purposes. South Perth Hospital would like you to indicate on thisform whether or not you consent to the use of the personal information it holds about you for thepurposes described below.

You are under no obligation to provide consent to the use of your personal information for any of thepurposes described below. In the event that you do not consent, we will respect your wishes and willnot use the information in any way that shows your personal details.

Please initial each box indicating your consent- any boxes left blank will denote that consent is withheld.

To assist other Medical Practitioners or Institutions who may treat me in the future but only tothe extent necessary to treat or provide care for the particular condition I have consulted theMedical Practitioner or Institution about. This may include a requirement to forward relevantprior information, for example anaesthesia records.

To inform next of kin or authorised persons identified in my admission form of the outcome oftreatment or to obtain consent to necessary treatment when I am not able to provide suchconsent.

For clinical auditing projects for performance improvement undertaken by South PerthHospital in its own right or in conjunction with Medical Practitioners who work in the facility.

To assist South Perth Hospital in providing continuous improvement and staff developmentactivities.

DATED this day of 20Signature

Print Full Name Please

MR 1ASouth Perth Hospital


NRMEMANRUS

GIVEN NAMES

XES.B.O.D

DOCTORS NAME

SOUTH PERTHHOSPITAL

PATIENT TO COMPLETE


AFFIX ID LABEL HERE


Please Use ID Label When AvailableSURNAME MRN

GIVEN NAMES

D.O.B. SEX

DOCTORS NAME


Please answer the questions by tickingthe appropriate box

IT IS ESSENTIAL TO NOTIFY THE HOSPITAL IF YOU WEIGH 120KG OR MORE

Please give any necessary details in the spaces provided.If extra space is required, add a separate sheet of paper.�

1. Have you previously been hospitalised? No Yes � For what conditions? Please specify:

3. Do you take any regular medications? No Yes � Please list them below:(e.g. tablets, pills, Injections, puffers, aspirin or natural therapies)

Year Condition / Procedure



5. Does a general anaesthetic cause any unusual No Yes � If Yes, please specify: .......................................reaction to you? ..............................................................................

6. Does a general anaesthetic cause any unusual No Yes � If Yes, please specify: .......................................reaction to your family? ..............................................................................

Please specify relationship: .............................

..............................................................................

7. Do you have any questions / concerns No Yes � If Yes, please specify: ........................................about your hospital discharge? ..............................................................................

......................................................................................................................................................................................................

2. Do you have any allergies / unusual reactions? No Yes � What are they? What reaction did you have?(especially to medicines, sticking plaster or food)

......................................................................................................................................................................................................

......................................................................................................................................................................................................

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PATIENT TO COMPLETE


AFFIX ID LABEL HERE


Please Use ID Label When AvailableNRMEMANRUS

GIVEN NAMES

XES.B.O.D

DOCTORS NAME


The following question should be

Please Indicate: Your weight ________kg Height _________cm

answered by ticking the appropriate boxAny necessary details should be given in the spaces provided. If extra space is required, please add a separate sheet of paper.

Have you been hospitalised before? No Yes For what conditions? Please specify below

3. Do you take any regular medications? No Yes Please list them below:(e.g. tablets, pills, Injections, puffers, aspirin or natural therapies)

erudecorP / noitidnoCraeY



5. Does a general anaesthetic cause any unusual No Yes If Yes, please specify: .......................................reaction to you? ..............................................................................

6. Does a general anaesthetic cause any unusual No Yes If Yes, please specify: .......................................reaction in your family? ..............................................................................

Please specify relationship: ...........................................................................................................

7. Do you have any questions / concerns No Yes If Yes, please specify: ........................................about your hospital discharge? ..............................................................................

......................................................................................................................................................................................................

2. Do you have any allergies / unusual reactions? No Yes What are they? What reaction did you have?(especially to medicines, sticking plaster or food)

......................................................................................................................................................................................................

......................................................................................................................................................................................................

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PATIENT TO COMPLETE

CONSENT TO USEINFORMATION

We acknowledge our obligations to you under the Privacy Amendment (Private Sector) Act 2000.

Personal information we collect from you will be used primarily to ensure that you receive optimalcare, but may also be used for other purposes. South Perth Hospital would like you to indicate on thisform whether or not you consent to the use of the personal information it holds about you for thepurposes described below.

You are under no obligation to provide consent to the use of your personal information for any of thepurposes described below. In the event that you do not consent, we will respect your wishes and willnot use the information in any way that shows your personal details.

Please initial each box indicating your consent- any boxes left blank will denote that consent is withheld.

To assist other Medical Practitioners or Institutions who may treat me in the future but only tothe extent necessary to treat or provide care for the particular condition I have consulted theMedical Practitioner or Institution about. This may include a requirement to forward relevantprior information, for example anaesthesia records.

To inform next of kin or authorised persons identified in my admission form of the outcome oftreatment or to obtain consent to necessary treatment when I am not able to provide suchconsent.

For clinical auditing projects for performance improvement undertaken by South PerthHospital in its own right or in conjunction with Medical Practitioners who work in the facility.

To assist South Perth Hospital in providing continuous improvement and staff developmentactivities.

DATED this day of 20Signature

Print Full Name Please

MR 1ASouth Perth Hospital


NRMEMANRUS

GIVEN NAMES

XES.B.O.D

DOCTORS NAME

SOUTH PERTHHOSPITAL

PATIENT TO COMPLETE


AFFIX ID LABEL HERE



GIVEN NAMES

D.O.B. SEX

DOCTORS NAME


Please answer the questions by tickingthe appropriate box

IT IS ESSENTIAL TO NOTIFY THE HOSPITAL IF YOU WEIGH 120KG OR MORE

Please give any necessary details in the spaces provided.If extra space is required, add a separate sheet of paper.�

1. Have you previously been hospitalised? No Yes � For what conditions? Please specify:

3. Do you take any regular medications? No Yes � Please list them below:(e.g. tablets, pills, Injections, puffers, aspirin or natural therapies)

Year Condition / Procedure



5. Does a general anaesthetic cause any unusual No Yes � If Yes, please specify: .......................................reaction to you? ..............................................................................

6. Does a general anaesthetic cause any unusual No Yes � If Yes, please specify: .......................................reaction to your family? ..............................................................................

Please specify relationship: .............................

..............................................................................

7. Do you have any questions / concerns No Yes � If Yes, please specify: ........................................about your hospital discharge? ..............................................................................

......................................................................................................................................................................................................

2. Do you have any allergies / unusual reactions? No Yes � What are they? What reaction did you have?(especially to medicines, sticking plaster or food)

......................................................................................................................................................................................................

......................................................................................................................................................................................................

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ADMITTING DOCTOR TO COMPLETE



CONSENT TOPROCEDURE

TO BE COMPLETED IN FULL BY ADMITTING DOCTOR


GIVEN NAMES

XES.B.O.D

DOCTORS NAME

Doctor’ etaD noitarepOemaN s

emiT noissimdAetaD noissimdA

Special Requirements:

tneitapnItneitaptuOyregruS yaD

HOSPITALSOUTH PERTH

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I, ........................................................................................................................................ hereby consent to the procedure of(Name of patient)

...........................................................................................................................................................................................................................

...........................................................................................................................................................................................................................

...........................................................................................................................................................................................................................(Use no abbreviations, please print clearly)

being performed on my(If not self, state patient’s name and relationship)

The nature and purpose of which has been explained to me by .............................................................................................

..........................................................................................................................................................................

(Medical Practitioner‘s name)

PATIENT’S DECLARATION

Signed .......................................................................................................................

...........................................................................................................................................................................................................................

Date .............................................................(Patient / Guardian)

Medical Officer’s Confirmation

Signed ...................................................................................................................... Date .............................................................(Medical Officer)

IMPORTANT INFORMATIONPLEASE RETAIN THIS PAGE FOR YOUR INFORMATION

PLEASE MAKE SURE YOU READ THE FOLLOWING PRIOR TO YOUR ADMISSIONCommitment to QualityOur staff are committed to quality care and to providing a service

that meets all your expectations. Our achievements have beenrecognised by the Australian Council on Healthcare Standards andwe have been awarded four-year accreditation status. Your care andcomfort is our primary concern and we encourage you to ask ourstaff for anything you require or about anything you wish to knowduring your stay with us.

Hospital FeesIf you have private health insurance you may be required to pay

an excess or co-payment at the time of your admission. Pleaseverify your level of cover with your fund and ensure that yourhealth fund payments are up-to-date prior to your admission.

If you are uninsured you will be required to pay the estimatedcost of your hospital and theatre fees prior to your admission.Please obtain an estimate of the payment required prior to youradmission by contacting Patient Billing on (08) 9367 0222.

The hospital has EFTPOS facilities and accepts major credit cards(Bankcard, Visa, Mastercard).

Please note we do not accept personal cheques above the value of$150-00.

Pre-Operative Instructions

If you are admitted for surgery you must:

• Fast from food and liquid from the time advised byyour doctor;

• Remove all jewellery and body piercings prior tocoming to hospital;

• Remove all make-up and nail polish prior to coming tohospital.

Ambulance ServicesThere may be a charge for using ambulance services for patients

transferring to or from home to hospital and inter-hospitaltransfers. Please check with your Health Insurance Fund and/or StJohns Ambulance to find out if you are covered for these services.

Pharmacy ServicesWhilst you are in hospital, some of your medications ordered by

your doctor, may be dispensed by the Community Pharmacy(which is located across the road from the hospital)

Please provide details of any Pharmaceutical Benefit Cards (e.gPension, Repatriation, Safety Net Concessions etc.) to the hospital at your time of admission. If we do not have your concession details, prescriptions and medications will be charged by the Pharmacy atnon-concession prices.

Pharmacy VisitsDuring your stay in hospital you may receive a visit from the

pharmacist who will be very happy to answer any questions aboutyour medications. If you require other items from the pharmacyplease notify the staff at the hospital or the pharmacy.

Please settle your pharmacy account promptly upon your dischargefrom the hospital.

Community PharmacyCnr Coode Street & South Terrace, Como 6152.

Phone (08) 9367 1584 Fax (08) 9367 9782

Visiting HoursMedical/Surgical 8.00am – 8.00pm

What to bring to hospital- Health Fund/Medicare details- Pharmacy concession details- Any letter/s from your doctor- Any relevant x-rays- Medications you are currently taking in their original packet- Night attire and personal toiletries.Please do not bring large sums of cash or valuables as the hospital

cannot accept responsibility for the loss of any valuables.DO NOT BRING ELECTRICAL APPLIANCESTO HOSPITAL.

ParkingFree parking is available in the car park off Burch Street at the rear

of the hospital for patients and visitors.

Pastoral CarePastoral care and chaplaincy services are available upon request

to ensure your emotional and spiritual comfort.

Gourmet MealsOur kitchens are run by a talented team who produce a variety of

gourmet hot and cold dishes. If you have any special requests ordietary requirements please ensure this information is noted on thePatient Health History form (Special Indicators section) and advisethe nurse on admission.

Room AllocationsAll rooms have ensuites with shower and toilet facilities. Single

rooms are subject to availability and every effort is made toaccommodate your request as soon as possible.

Boarder FacilitiesIf your child is expected to stay overnight it is preferable that a

parent stays with them. Please contact the hospital for furtherinformation as we are very happy to assist.

TelephonesA telephone is provided by each bed. You will be charged for long

distance and calls to mobile phones.

TelevisionEach bed has its own television at no extra cost.

No Smoking PolicySmoking is banned on all hospital property including a 5 meter

perimeter around hospital boundaries. If needed, discuss nicotinereplacement therapy with your doctor before admission.

Going home once dischargedPlease present to the front reception desk to finalise your

discharge prior to leaving the hospital. On discharge we requestthat you pay any charges that have not already been settled. Pleasearrange transport to and from the hospital.

Infection Control InformationPreventing infection in the hospital - what you can do -

information available www.npsf.org.

HOSPITALSOUTH PERTHInterpreter/Hearing Impaired Services

Should these be required, please notify the hospital before admission.



AFFIX ID LABEL HERE

CONSENT TOPROCEDURE


SPECIAL REQUIREMENTS/INSTRUCTIONS (eg - Physical /Intellectual Disability)

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

SIGNIFICANT PAST HISTORY MEDICAL/SURGICAL/ANAESTHETIC (Including Co-morbidities)

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

PROVISIONAL DIAGNOSIS

............................................................................................................................................................................................................................

............................................................................................................................................................................................................................


GIVEN NAMES

D.O.B. SEX

DOCTORS NAME

Doctor’s Name Operation Date

Admission Date Admission Time

Day Surgery Outpatient Inpatient

HOSPITALSOUTH PERTH

MR

2

CO

NS

EN

TT

OP

RO

CE

DU

RE

Rev

iew

ed J

anua

ry 2

005

I, ..............................................................................................hereby consent to the procedure of CMBS No.Name

........................................................................................................................................................................ ............................................No abbreviations, please print

........................................................................................................................................................................ ............................................

........................................................................................................................................................................ ............................................

being performed on my ......................................................................................................................... ............................................If not self, state patient’s name and relationship

The nature and purpose of which has been explained to me by .............................................................................................Medical Practitioner’s name

During your procedure, there is a possibility of a staff member or doctor being injured and contaminated with your blood.Should this situation arise, we request your consent for blood to be collected and tested for infectious agents.

Consent to Blood TestIf any staff member or doctor is injured and exposed to my (or my child’s) blood or other body fluid, then I give consent toblood being collected from myself or my child and tested for infectious agents, including Hepatitis B, Hepatitis C and the HIVantibody.

I understand:

1. that I will be informed that blood has been taken for testing;

2. that the results of the test will be made available to me, the staff member or the doctor injured and the Infection ControlOfficer of South Perth Hospital (or his/her deputy);

3. that the staff and doctor are bound by the Hospital policy to maintain confidentiality of the test results;

4. should the test result be positive the Privacy Act is waived and the Health Department of Western Australia will benotified;

5. the treating Medical Officer will be notified of the result.

Signed ....................................................................................................................... Date .............................................................(Patient / Parent / Guardian)

MEDICAL PRACTITIONER’S CONFIRMATIONI confirm that I have explained to the patient/guardian the nature and purpose of this procedure.

Signed ...................................................................................................................... Date .............................................................Medical Practitioner

~ I also consent to the administration of local or general anaesthetics, drug medications, blood transfusions or other forms of treatment normally associated with this operation/procedure/treatment such as pathology or radiology services.~ I understand that further unexpected operations/procedures/treatments may be necessary and I request that these be carried out if required.~ Although this operation/procedure/treatment is carried out with all due professional care and responsibility, I understand that in some circumstances the expected result may not be achieved.~ I also understand that complications may occur with any operation/procedure/treatment, and I accept the possible risks associated with this operation/procedure/treatment.~ I understand that photographs or video footage may be taken during my operation. These may be used for teaching health professionals. (You will not be identified in any photo/video)~ In the event of any staff member or doctor being injured or exposed to my/my child’s blood or body fluids during the operation/procedure/treatment, I consent to having blood collected for the testing of communicable disease, including Hepatitis B & C and HIV.~ I understand that: - I will be informed if blood for testing has been taken - the results of the test will be made available to me, the staff member or the doctor injured and the South Perth

Hospital Infection Control Nurse (or their deputy) - the staff and doctor are bound by the Hospital’s Confidentiality Policy - should the test results be positive, the Privacy Act is waived and the Department of Health (WA) will be

notified. - the treating medical officer will also be informed of the results.Please note in the space provided below, any operation/procedure/treatment that you do not want to consent to:

I confirm that I have explained to the patient/guardian the nature and purpose of the above mentioned operation/procedure/treatment, any alternative treatments available and the benefits and risks of the purposed.





CONSENT TOPROCEDURE



GIVEN NAMES

XES.B.O.D

DOCTORS NAME

Doctor’ etaD noitarepOemaN s

emiT noissimdAetaD noissimdA

Special Requirements:

tneitapnItneitaptuOyregruS yaD

HOSPITALSOUTH PERTH

MR

2

CO

NS

EN

TT

OP

RO

CE

DU

RE

I, ........................................................................................................................................ hereby consent to the procedure of(Name of patient)

...........................................................................................................................................................................................................................

...........................................................................................................................................................................................................................

...........................................................................................................................................................................................................................(Use no abbreviations, please print clearly)

being performed on my(If not self, state patient’s name and relationship)

The nature and purpose of which has been explained to me by .............................................................................................

..........................................................................................................................................................................

(Medical Practitioner‘s name)

PATIENT’S DECLARATION

Signed .......................................................................................................................

...........................................................................................................................................................................................................................

Date .............................................................(Patient / Guardian)

Medical Officer’s Confirmation

Signed ...................................................................................................................... Date .............................................................(Medical Officer)

IMPORTANT INFORMATIONPLEASE RETAIN THIS PAGE FOR YOUR INFORMATION

PLEASE MAKE SURE YOU READ THE FOLLOWING PRIOR TO YOUR ADMISSIONCommitment to QualityOur staff are committed to quality care and to providing a service

that meets all your expectations. Our achievements have beenrecognised by the Australian Council on Healthcare Standards andwe have been awarded four-year accreditation status. Your care andcomfort is our primary concern and we encourage you to ask ourstaff for anything you require or about anything you wish to knowduring your stay with us.

Hospital FeesIf you have private health insurance you may be required to pay

an excess or co-payment at the time of your admission. Pleaseverify your level of cover with your fund and ensure that yourhealth fund payments are up-to-date prior to your admission.

If you are uninsured you will be required to pay the estimatedcost of your hospital and theatre fees prior to your admission.Please obtain an estimate of the payment required prior to youradmission by contacting Patient Billing on (08) 9367 0222.

The hospital has EFTPOS facilities and accepts major credit cards(Bankcard, Visa, Mastercard).

Please note we do not accept personal cheques above the value of$150-00.

Pre-Operative Instructions

If you are admitted for surgery you must:

• Fast from food and liquid from the time advised byyour doctor;

• Remove all jewellery and body piercings prior tocoming to hospital;

• Remove all make-up and nail polish prior to coming tohospital.

Ambulance ServicesThere may be a charge for using ambulance services for patients

transferring to or from home to hospital and inter-hospitaltransfers. Please check with your Health Insurance Fund and/or StJohns Ambulance to find out if you are covered for these services.

Pharmacy ServicesWhilst you are in hospital, some of your medications ordered by

your doctor, may be dispensed by the Community Pharmacy(which is located across the road from the hospital)

Please provide details of any Pharmaceutical Benefit Cards (e.gPension, Repatriation, Safety Net Concessions etc.) to the hospital at your time of admission. If we do not have your concession details, prescriptions and medications will be charged by the Pharmacy atnon-concession prices.

Pharmacy VisitsDuring your stay in hospital you may receive a visit from the

pharmacist who will be very happy to answer any questions aboutyour medications. If you require other items from the pharmacyplease notify the staff at the hospital or the pharmacy.

Please settle your pharmacy account promptly upon your dischargefrom the hospital.

Community PharmacyCnr Coode Street & South Terrace, Como 6152.

Phone (08) 9367 1584 Fax (08) 9367 9782

Visiting HoursMedical/Surgical 8.00am – 8.00pm

What to bring to hospital- Health Fund/Medicare details- Pharmacy concession details- Any letter/s from your doctor- Any relevant x-rays- Medications you are currently taking in their original packet- Night attire and personal toiletries.Please do not bring large sums of cash or valuables as the hospital

cannot accept responsibility for the loss of any valuables.DO NOT BRING ELECTRICAL APPLIANCESTO HOSPITAL.

ParkingFree parking is available in the car park off Burch Street at the rear

of the hospital for patients and visitors.

Pastoral CarePastoral care and chaplaincy services are available upon request

to ensure your emotional and spiritual comfort.

Gourmet MealsOur kitchens are run by a talented team who produce a variety of

gourmet hot and cold dishes. If you have any special requests ordietary requirements please ensure this information is noted on thePatient Health History form (Special Indicators section) and advisethe nurse on admission.

Room AllocationsAll rooms have ensuites with shower and toilet facilities. Single

rooms are subject to availability and every effort is made toaccommodate your request as soon as possible.

Boarder FacilitiesIf your child is expected to stay overnight it is preferable that a

parent stays with them. Please contact the hospital for furtherinformation as we are very happy to assist.

TelephonesA telephone is provided by each bed. You will be charged for long

distance and calls to mobile phones.

TelevisionEach bed has its own television at no extra cost.

No Smoking PolicySmoking is banned on all hospital property including a 5 meter

perimeter around hospital boundaries. If needed, discuss nicotinereplacement therapy with your doctor before admission.

Going home once dischargedPlease present to the front reception desk to finalise your

discharge prior to leaving the hospital. On discharge we requestthat you pay any charges that have not already been settled. Pleasearrange transport to and from the hospital.

Infection Control InformationPreventing infection in the hospital - what you can do -

information available www.npsf.org.

HOSPITALSOUTH PERTHInterpreter/Hearing Impaired Services

Should these be required, please notify the hospital before admission.



AFFIX ID LABEL HERE

CONSENT TOPROCEDURE


SPECIAL REQUIREMENTS/INSTRUCTIONS (eg - Physical /Intellectual Disability)

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

SIGNIFICANT PAST HISTORY MEDICAL/SURGICAL/ANAESTHETIC (Including Co-morbidities)

.........................................................................................................................................................................................................................

.........................................................................................................................................................................................................................

PROVISIONAL DIAGNOSIS

............................................................................................................................................................................................................................

............................................................................................................................................................................................................................


GIVEN NAMES

D.O.B. SEX

DOCTORS NAME

Doctor’s Name Operation Date

Admission Date Admission Time

Day Surgery Outpatient Inpatient

HOSPITALSOUTH PERTH

MR

2

CO

NS

EN

TT

OP

RO

CE

DU

RE

Rev

iew

ed J

anua

ry 2

005

I, ..............................................................................................hereby consent to the procedure of CMBS No.Name

........................................................................................................................................................................ ............................................No abbreviations, please print

........................................................................................................................................................................ ............................................

........................................................................................................................................................................ ............................................

being performed on my ......................................................................................................................... ............................................If not self, state patient’s name and relationship

The nature and purpose of which has been explained to me by .............................................................................................Medical Practitioner’s name

During your procedure, there is a possibility of a staff member or doctor being injured and contaminated with your blood.Should this situation arise, we request your consent for blood to be collected and tested for infectious agents.

Consent to Blood TestIf any staff member or doctor is injured and exposed to my (or my child’s) blood or other body fluid, then I give consent toblood being collected from myself or my child and tested for infectious agents, including Hepatitis B, Hepatitis C and the HIVantibody.

I understand:

1. that I will be informed that blood has been taken for testing;

2. that the results of the test will be made available to me, the staff member or the doctor injured and the Infection ControlOfficer of South Perth Hospital (or his/her deputy);

3. that the staff and doctor are bound by the Hospital policy to maintain confidentiality of the test results;

4. should the test result be positive the Privacy Act is waived and the Health Department of Western Australia will benotified;

5. the treating Medical Officer will be notified of the result.

Signed ....................................................................................................................... Date .............................................................(Patient / Parent / Guardian)

MEDICAL PRACTITIONER’S CONFIRMATIONI confirm that I have explained to the patient/guardian the nature and purpose of this procedure.

Signed ...................................................................................................................... Date .............................................................Medical Practitioner

~ I also consent to the administration of local or general anaesthetics, drug medications, blood transfusions or other forms of treatment normally associated with this operation/procedure/treatment such as pathology or radiology services.~ I understand that further unexpected operations/procedures/treatments may be necessary and I request that these be carried out if required.~ Although this operation/procedure/treatment is carried out with all due professional care and responsibility, I understand that in some circumstances the expected result may not be achieved.~ I also understand that complications may occur with any operation/procedure/treatment, and I accept the possible risks associated with this operation/procedure/treatment.~ I understand that photographs or video footage may be taken during my operation. These may be used for teaching health professionals. (You will not be identified in any photo/video)~ In the event of any staff member or doctor being injured or exposed to my/my child’s blood or body fluids during the operation/procedure/treatment, I consent to having blood collected for the testing of communicable disease, including Hepatitis B & C and HIV.~ I understand that: - I will be informed if blood for testing has been taken - the results of the test will be made available to me, the staff member or the doctor injured and the South Perth

Hospital Infection Control Nurse (or their deputy) - the staff and doctor are bound by the Hospital’s Confidentiality Policy - should the test results be positive, the Privacy Act is waived and the Department of Health (WA) will be

notified. - the treating medical officer will also be informed of the results.Please note in the space provided below, any operation/procedure/treatment that you do not want to consent to:

I confirm that I have explained to the patient/guardian the nature and purpose of the above mentioned operation/procedure/treatment, any alternative treatments available and the benefits and risks of the purposed.


Documents

SOUTH PERTH Pre-admission Form HOSPITAL Pre-admission Form · Pre-admission Form To confirm your booking, please complete this form and forward to Admissions, South Perth Hospital,