Cosmetic Surgery Clinic: Patients Service Centre: Registration Form

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PATIENT REGISTRATION FORM

DARRYL J. HODGKINSON M.D. F.R.C.S.(C) F.A.C.S.

Name (print)				Gender:	(M) (F)	Mr Mrs Ms Miss	Other:
Address						Postcode:
Telephone	H:	W:	M:	Age:		Birthdate:
Email		Medicare:		Private Fund Name & Number:
Occupation			Birth Country:			Language at home:
Next Of Kin					Relationship:
Address				Postcode:		Telephone:
GP's Name, Address
How did you hear about the Clinic? (Please circle)	Previous patient	Friend	General Practitioner	Specialist	Television	Internet	Yellow Pages
How did you hear about the Clinic? (Please circle)	Magazine:		Newspaper:		Local Paper:		Other:

BODY AREA	X Please	Procedure	Quotation	BODY AREA	X Please	Procedure	Quotation
BREAST		Breast Implants		FACE		Facelift
		Breast Lift				Browlift
		Breast Reduction				Cheek Implants
		Breast Reconstruction				Chin Implants
		Capsulotomy (Open/Closed)				Lower Lids
		Implant Removal				Upper Lids
		Implant Removal /Re-augment		NOSE		Rhinoplasty
		Nipple Revision		EARS		Otoplasty
		Gynaecomazia		LINES		Laserbrasion
BODY		Liposuction				Dermabrasion
		Tummy Tuck				Chemical Peel
		Thigh Lift				Collagen Injections
		Upper Arms Lift				Anti-wrinkle Injections
		Pectoral Implants		LIPS		Lip Augmentation
		Calf Implants		OTHER		Lesion Removal
		Tricep Implants				Scar Revision
		Buttock Implants				Cancer Reconstruction
						Buccal Fat Pad Removal
						Fat Injections

It is customary in Australia as in the USA and elsewhere to request pre-payment of fees for cosmetic surgery. For your allocated time to be reserved on the operating schedule, full payment of the surgical fee is required fourteen days prior to the date of surgery. The surgical fee is paid for the performance of the operation and the supervision of the post-operative care. Although the utmost skill and care are applied for the best result, it is not possible to guarantee the optimal outcome. Your fee is therefore not paid for a guaranteed result.

I hereby consent to be photographed before, during and after the treatment. I understand these photographs are very important for the Doctor and myself in allowing us to communicate objectively about our goals pre-operatively and about what we have achieved post-operatively. These photos shall be the property of Dr Hodgkinson and may be used as he deems proper for scientific and educational purposes. My consent is subject only to the consideration that I not be identified by name at any time during any scientific use or publication. The photos are not to be used in the popular media without my further consent.

Patient’s Name (Please Print)	_____________________________________________
Patient’s Signature	_____________________________________________
Date	_____________________________________________

IF THE PATIENT IS A MINOR, COMPLETE THE FOLLOWING

The patient is a minor of ______ years of age; and we, the undersigned, are the parents or legal guardian of the patient and do hereby consent for the patient.

Parent or Legal Guardian ______________________________________________________________

Witness____________________________________________________________________________

20 Manning Road Double Bay N.S.W. 2028 Telephone: (02) 9362 7400 Facsimile: (02) 9328 6036

Please read our Legal Notices

The Cosmetic and Restorative Surgery Clinic and the Double Bay Day Surgery
20 Manning Road, Double Bay 2028, Australia
tel:+61 (2) 9362 7400 fax:+61 (2) 9328 6036