McCourt Street Day Surgery | Patient Pre-Admission Form

Health Insurance Information - Informed Financial Consent
**Bring Health Insurance Cards on Admission - Check with your Fund to ensure you have held membership for longer than 12 consecutive months**
Medicare No.
Ref No.
Name of Insurance Fund
Fund Membership No
DO YOU HAVE AN EXCESS ON YOUR POLICY?
- Yes
- No
(Please check with your Health Fund before admission)
EXCESS AMOUNT $
Excess will need to be paid to McCourt St Day Surgery on admission
UNINSURED DAY SURGERY FEE $
Fee will need to be paid to McCourt St Day Surgery on admission
Patient’s Signature
Click here to create your own digital signature
Person or Party Responsible For Payment
(Do not complete if person is the patient)
Surname
Given Names
Address
Postcode
Relationship to Patient
Home Phone
Work Phone

Hospital Questions
Have you been a patient at this hospital before?
- No
- Yes
Which year?
Previous name if different to this admission
Have you been hospitalised interstate or overseas in the last 12 months?
- No
- Yes
Where?

Medications / Natural Medications
Please list your current medications and dosage
TYPE DOSAGE
Have you ever taken or are you taking any of the following?
If yes, when did you stop taking
Aspirin
- Yes
- No
Date Ceased
Date Format: MM slash DD slash YYYY
Blood Thinners (eg; Warfarin)
- Yes
- No
Date Ceased
Date Format: MM slash DD slash YYYY
Steroid/Cortisone/Prednisolone
- Yes
- No
Date Ceased
Date Format: MM slash DD slash YYYY
Insulin
- Yes
- No
Date Ceased
Date Format: MM slash DD slash YYYY

Transport Questions
Have you arranged transport with a responsible adult and someone to stay with you for the next 24 hours?
- Yes
- No
- N/A
Patient / Guardian Signature
Date
Date Format: MM slash DD slash YYYY

Patient Pre-Admission Form

TYPE	DOSAGE