Patient Admission Form  
 
  PATIENT INFORMATION    
    To be completed in full by patient one week prior to admission.    
  Date of admission           
  Surgeon     
  Have you been a patient in this hospital before
YES    NO   Year       		    
  Have you been admitted to hospital in the last 2 months
1/ No    2/ This hospital      3/ Other hospital  		    
 
Personal DetailsPatient Name:
 
  Title      Surname         Previous surname (if applicable)     
  Given names    
   Sex:     Male        Female     Date of birth    
  Address       Suburb     
  State        Postcode        Email address    
  Mobile phone     Phone private     Phone business     
  Marital Status:    Married        Defacto        Separated        Single        Widowed        Divorced    
  Religion       
  Country of birth      
  Aboriginality   1/ Aboriginal    2/ Torres Straight Islander   3/ Neither  
  Main languages spoken at home    
  Country of perm. residency      
 
Medicare No Patient Name:
 
  Expiry Date      Patient's line number    
 
Pension InformationPatient Name:
 
  Please fill out the following if you are a pensioner or dependant  
  Pension no.      Exp.  
  H.C.C. no.      Exp.  
  Veteran Affairs      Card / Colour  
 
Next of kin / Contact 1Patient Name:
 
  Name        
  Address       Suburb    
  State        Postcode    
  Phone private     Phone business     
  Relationship      
 
Next of kin / Contact 2Patient Name:
 
  Name        
  Address       Suburb    
  State        Postcode    
  Phone private     Phone business     
  Relationship      
  General Practioner (GP)     
  Address       Suburb    
  State        Postcode    
 
Overnight Accomodation PreferredPatient Name:
 
  (While no guarantee can be given, every effort will be made to accomodate patients as requested)            Private room   Shared ward  
 
Hospital InsurancePatient Name:
 
  Name of fund      What is your excess     
  Membership No      Name on membership card    
 
Cause of Injury (if applicable)Patient Name:
 
  Cause of injury      Date of injury     
  If injury, where did it occur:  
 
0 Home 1 Residential institution
2 School, other institution, public administrative area 3 Sports & athlectics area
4 Streets & highways 5 Trade & service area
6 Industrial & construction sie 7 Farm
8 Other specified place 9 Unspecified place
 
 
Worker's CompensationPatient Name:
 
  Liability must be accepted before admission  
  Date of accident      Employer     
  Address       Suburb    
  State        Postcode      Phone     
  Insurance company     
  Address       Suburb    
  State        Postcode      Phone     
  Contact name     
  Claim number * required field     
  Your solicitor     
  Address       Suburb    
  State        Postcode      Phone     
 
Third Party / TranscoverPatient Name:
 
  Date of accident      Claim number * required field     
  Insurance company     
  Address       Suburb    
  State        Postcode      Phone     
  Your solicitor     
  Address       Suburb    
  State        Postcode    
  PAYMENT OF ACCOUNTS  
  The balance of the account is payable at the time of admission and patients without insurance are required to settle their account on admission.
INFORMED FINANCIAL CONSENT   I understand and agree to pay all hospital accounts including any denied by - Health Insurance Funds, WorkCover, Transport Accident Commission or any other relevant body. I understand that the hospital will not be liable for any valuables I bring to the hospital.		  
  Agree to the above * required  
  Person responsible for the account      
  Are the details the same as the patient details filled in at top of this form    NO  (if answer is NO, fill in details below)    YES (leave out next 5 questions)  
  Surname      Given names    
  Address       Suburb    
  State        Postcode        Email address    
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