Are You A Patient?

Thank you for filling out this form so that we have your details ready for your appointment with Dr. Yanez Peerbacus at GastroMed

The Information you provided will be securely sent to us & we will add it to your file for the doctor.
If you have any questions at all, please contact us on email reception@gastromedbrisbane.com.au
or phone 0402 363 012

"*" indicates required fields

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This field is for validation purposes and should be left unchanged.

Personal Details:

Title

Date of Birth*

First Name*

Last Name*

Email*

Age*

Gender

Do you identify as Aboriginal and / or Torres Strait Islander origin?*

Street Address*

Suburb*

Postcode*

State*

Home Phone

Mobile Phone*

Work Phone

Next of kin: Name*

Phone*

Relationship*

Emergency Contact: Same as above?*

Yes

Name

Phone

Insurance & Medicare Details:

Medicare Number

Ref

Expiry

Department of Veterans Affairs Number

Colour

Expiry

Health Fund Name

Membership Number

HealthCare Card/Pension Card Number

Expiry

Referring Doctor*

Practice Name*

Health Questionnaires:

Please list any known allergies/reactions*

Please list all current medications & dosage*

Consent to use personal information:

In accordance with the Privacy Act (1998) all information collected in this practice is treated as sensitive information. To protect your privacy, this practice operates in according to this Act. We used this information that you provide to manage your health care. You can assist in maintaining the accuracy of your information by advising the practice of changes of address, phone numbers etc. Selected information may be disclosed to various other health services involved in supporting your health care management (i.e pathology, radiology, general practitioners or medical specialists, public or private hospitals).

Our practice uses a reminder system to help you maintain your health. The practice sends reminders for procedures such as colonoscopy, Upper GI/Endoscopy, removal of gastric balloon & other health reviews.

I consent to being contacted with reminders to help me maintain my health.

Consent Option*

Yes

I hereby confirm that the information provided is accurate to the best of my knowledge.

File

Max. file size: 64 MB.

Signature Of Patient*

Date

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Find the Right Care for Your Gastrointestinal Health

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