Patient Admission Details & Medical History Form

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Clinic *

Patient Admission Details & Medical History Form

Title *

Patient's Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mobile Number *

Home Phone

Work Number

Email *

Medicare No. *

Medicare ref No. *

Medicare Exp Date: *

Heath Fund Name:

Member No.

Pension/ Healthcare Card No:

Expiry Date:

Next of Kin & best contact number in case of emergency

Name of next of kin *

First

Last

Relationship to next of kin *

Contact Number or next of kin *

Medical History

Do you have any allergies? *

Nil Known
Yes

Allergies:

Please list any known allergies and your reaction.

Do you have a heart disease? *

Heart disease details

Do you have renal/kidney disease? *

Renal / Kidney disease details

Are you on fluid restrictions? *

Fluid restrictions details

Are you diabetic? *

Diabetes details

Do you have any other Medical Conditions? *

Please list any other medical conditions:

Do you take any Medications or Supplements? *

Current Medications

Please list the current medications you are taking.

FEMALE PATIENTS:

Could you be pregnant?

No
Yes
Unsure

If yes, how many weeks gestation are you?

NOTE: It is unsafe to administer Iron before 16 weeks gestation.

General Practitioner or Specialist Information

Name of your GP or Specialist *

First

Last

Phone Number of GP or Specialist *

Address of GP or Specialist: *

Consent Declaration

I confirm that all the above details are correct. have read all the patient information and any questions have been answered to my satisfaction.

I agree that my personal and health information will be handled in accordance with The Infusion Clinic's Privacy Policy available at www.infusionclinic.com.au/privacy-policy

I consent to the placement of an intravenous cannula and administration of the medication I have been prescribed by my General Practitioner or Specialist

I understand these carry risks which have been explained to me by my prescribing doctor

I understand the potential adverse including: failed canulation, bruising, bleeding, pain, infection, allergy, anaphylaxis or, in the case of Iron Infusions staining of the skin.

Did you purchase your own medication? *

No (Purchased through recommended pharmacy)
Yes (please read below)

If you sourced & purchased your medication from a pharmacy the we did not recommend, please read below

I take full responsibility, and have ensured that the manufacturer's storage conditions as displayed on the external packaging have been adhered to

I unconditionally and indefinitely release and discharge The Infusion Clinic, it's related and associated bodies corporate, their officers, agents, employees, ad representatives from, and against all claims, liability, costs and demands whatsoever arising whether directly or indirectly, in respect of the integrity, safety of my own medication relating to its storage and supply for the purpose of the infusion therapy.

OFFICE USE ONLY: Print this form & ask patient to check the above information at their appointment

Please sign to confirm that the above information you have provided is correct.

Website

At The Infusion Clinic, our mission is to provide outpatient medical infusions in a state-of-the art facility to treat acute and chronic health conditions.

Treatments

Iron Infusions
Osteoporosis & Bone Health Infusions
IVF Infusions for NK Cells
Hydration & Medication Infusions
Injectables
Antibiotic Infusions
Venesections
Biologic Infusions
Other Infusions

Quick Links

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Email: bookings@infusionclinic.com.au

Opening Hours:
Mon – Fri 8.00am – 5.00pm
Sat 8.00am – 4.00pm

Locations:
Wales Medical Centre, Level 1, 66 High Street, Randwick NSW 2031
Ph: 1300 122 300

Suite 2, Level 1, 517 St Kilda Rd Melbourne VIC 3004
Ph: 1300 122 400

Suite 305, Level 3, 161 Bigge St, Liverpool NSW 2170
Ph: 1300 122 600

Home
About Us
Referrer Registration
Treatments
Appointments
Information
- Information for Patients
- Information For Doctors
Fees
FAQ’s
Contact