Patient Registration Step 1 of 5 20% PhoneThis field is for validation purposes and should be left unchanged.Level 1, 229 Great North Road, Five Dock, NSW 2046 Phone: 61 2 9713 4011 Fax: 61 2 9712 1675 Web: www.cdd.com.auPersonal DetailsName(Required) Prefix Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Middle Last AddressAddress Note: Medicare & Health Fund claims cannot be processed to PO Boxes. Street Address City State Postal Code Mobile Phone(Required)Home PhoneWork PhoneEmail Date Of Birth(Required) DD slash MM slash YYYY Country Of BirthAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsSex(Required)MaleFemaleMarital Status Married Single OccupationReligionIndigenous Status Aboriginal Torres Strait Island Neither Decline to answer Language SpokenNext Of KinName First Last PhoneEmail Relationship to patient Your Procedure at CDDThis field is hidden when viewing the formProceduralistDelete field - use Assigned doctor insteadThis field is hidden when viewing the formProcedureDelete Field - replace with Dr Use Procedure/OtherProcedure Colonoscopy Panendoscopy Other Have you been admitted here previously? Yes No YearPlease enter a number from 1990 to 2050.ReferralReferring Doctor Name Prefix Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Last Referring Doctors Phone NumberReferral AttachmentAccepted file types: jpg, png, gif, jpeg, pdf, doc, docx, jfif, webp, Max. file size: 10 MB. General HealthSelect all relevant optionsSelect all relevant options Heart Problems Pacemaker/Implants High Blood Pressure Stroke/Blood Clots Bleeding/Blood Disorder Thyroid Disorders Asthma/Lung Disease Heartburn/Reflux Advance Care Directive Arthritis Diabetes Hepatitis / liver disease Epilepsy Tuberculosis Kidney / bladder disease Sleep apnoea Wounds / breaks in skin Have you ever smoked Are you pregnant Significant Infection Eg. MRSA, VRE Recent respiratory infection eg. cold, flu Travel overseas in the last 14 days Hearing loss Walking aids Recent dental work Dementia / delirium Mental health condition eg. anxiety / bipolar Any other serious illness Further DetailsIf any of these boxes have been ticked, please provide further information:Smoking Status Current Smoker Previous Smoker Date Ceased Smoking DD slash MM slash YYYY Last Seizure Date DD slash MM slash YYYY Diabetes Type Type 1 Type 2 HeightHeight in cmWeightWeight In kgAllergies & Medical HistoryAllergiesPlease list allergies/adverse reactions (including foods,medication, latex etc)Medical HistoryPlease list major operations and dates (include all operations within the last six months)Have you or your family ever experienced problems with anaesthetic? No Yes DetailsMedicationsCurrent MedicationsPlease list all current medications (including HRT, the pill, complementary therapies)Are you currently or have you within the last 12 months taken Warfarin/Plavix blood thinning medication? No Yes Have you been instructed to cease this medication? No Yes Date Last Taken YYYY dash MM dash DD Discharge PlanningYou must have someone to take you home. You should have someone with you overnight.Do You Live Alone? No Yes Are you the sole carer for somone else? No Yes MedicareDo you have a medicare card? Yes No Medicare / Overseas Patient Medicare Number(Required)Exp Month(Required)Select010203040506070809101112Exp Year(Required)202420252026202720282028203020312032203320342035No. next to given name(Required)Medicare Card Colour Yellow (Reciprocal Card) Green (Standard) / Blue (Interim) Health Fund DetailsName Of Health FundMembership NumberPlease note: CDD will check your level of health fund cover prior to your procedure. However, it remains your responsibility to pay any out-of-pocket expense or health fund excess on the day of the procedure.Pension / Health Care CardPlease produce valid card on admissionPension NumberPension Expiry Date(Required)HCC NumberHCC Expiry Date(Required)Please note: As a pension card / HCC holder, all doctors fees will be bulk billed. However, there will be expenses not covered by Medicare for theatre and accommodation. You will be advised of the approximate cost prior to your procedure – this is payable on the day of your procedure.Veterans Affairs CardPlease produce valid card on admissionVA Card NumberVA Card Colour(Required) White Card Gold Card Uninsured PatientsCDD is a PRIVATE Day Hospital. You will need to pay expenses not covered by Medicare for doctors fees, theatre and accommodation. You will be quoted an approximate cost for your procedure – this is payable on the day of your procedure.Fees Consent(Required) I understand the fee arrangement No Medicare / International PatientsYou will need to pay the full cost for Doctors fees, theatre and accommodation. You will be quoted an approximated cost prior to your procedure – all fees are payable on the day of the procedure.Additional Pathology FeesPlease note that the Gastroenterologist performing your procedure may request Pathology services i.e.: Blood test, Biopsies, cultures etc.The following tests are sent out to various pathology companies according to the test required therefore you may receive accounts from more than one company.Unfortunately we are unable to predict what tests will be required until the procedure is carried out.Not all tests requested are a Medicare rebatable item and may incur additional costs to you.NB: PATHOLOGY EXPENSES WILL BE YOUR RESPONSIBILITY.The Pathology companies are not owned by CDD and all queries relating to their accounts must be directed to them.Pathology Consent(Required) I understand there may be additional pathology costs ConsentConsent(Required)I agree to the Centre for Digestive Diseases accessing all relevant infomation about my medical condition or history from other health care providers. I understand that to provide the highest quality medical care, my clinical records may be accessed and reviewed by staff of this practice and, in some circumstances other health care providers, and as required by law. I understand that my information will be handled in accordance with the Privacy Act 1988 and relevant amendments. I am aware there may be additional fees, charges and pathology costs that may not be covered by medicare or health insurance. (Required)Signature(Required) Δ
