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Home
Gallery
About Us
Procedures
Patients
Referrers
News
- Our Blog
- Media
MediSpa
Contact

New Patient Registration

"*" indicates required fields

Personal details

Name*

Title First Last

Address*

Street Address Address Line 2 City State

Date of birth*

DD slash MM slash YYYY

Occupation

Phone*

Email*

Name of emergency contact*

Title Given name Family name

Emergency contact's phone number*

Relationship of Emergency Contact*

Are you happy for us to discuss medical information, appointments & accounts with this person?*

Yes

No

How did you hear about Ethique Plastic Surgery?*

GP/doctor

Friends/family/word of mouth

Social media

Internet/website

Other

Name

Could you let us know who referred you?

Medicare & insurance details

Medicare number*

Please enter exactly 10 digits

Position number*

The number next to your name on the card

Expiry date*

Do you have private health insurance?*

Yes

No

Name of private health fund

Membership number

Do you have a veterans' affairs card?*

Yes

No

Veteran card type

Veterans' affairs number

Past medical history

Do you have or have you ever had any of the following medical conditions?*

Please select all that apply

Angina (heart pain) or heart attack

Hypertension (high blood pressure)

Stroke or temporary weakness on one side

Diabetes (high blood sugar)

Renal disease (kidney disease)

Respiratory illness (lung problems)

Bleeding disorder or clotting issues

Hepatitis (liver virus or disease)/HIV/AIDS

Cancer

Chicken pox or shingles

Recent viral illness (flu-like)

Other infections (such as MRSA, VRE, etc.)

Another condition not listed here

None of the above

What's the name of your condition? (if not listed above)

Please describe your treatment for the condition(s) selected

Do you smoke?*

Yes

No

If yes, how many do you smoke per day?

Do you have any problems with scarring or wound healing?*

Yes

No

If so, please specify

Have you undergone surgery in the past?*

Yes

No

If so, please list the operations you've had

Did you have difficulties with the anaesthetics?*

Yes

No

If so, please detail what happened

Did you suffer any complications related to your operations?*

Yes

No

If so, please detail your complications

Are you currently taking any medications (prescription, over-the-counter, or herbal)?*

Yes

No

If yes, please detail your medications

Which medications are you taking, how frequently, and in what dose?

Are you allergic to any medications?*

Yes

No

If yes, which medications are you allergic to?

GP contact details

GPs name

Prefix Given name Family name

GPs suburb

Do you have any other specialists?

Yes

No

Please provide their name and details

Agreement

Privacy agreement – In order to comply with the Privacy Laws (Privacy Act Amendments – Private Sector – Act 12/3/2014) your agreement to the following statement is required (patient or parent to complete):

Privacy agreement*

I agree to allow Ethique Plastic Surgery access to all relevant information regarding my medical conditions. I understand that they may be required to forward information about my medical condition or history to other health care providers. I understand that to provide the highest medical care, my clinical records may be accessed or reviewed by staff in this practice.

I understand and agree

Communication

We may send emails related to appointments, surgery, medical information, updates, our practice etc. We will not share your email address or to any other third party and you can unsubscribe at any time. If you do not want to receive these emails, please click here.

I do not wish to receive these emails

Clinical photography*

I agree that clinical photographs may be taken by Ethique Plastic Surgery as part of my consultation to be kept with my confidential medical records within this Practice.

I understand and agree

I do not agree

Educational photography*

I agree that my unidentifiable clinical photographs may be used for research, medical education or public education purposes.

I understand and agree

I do not agree

Signature*

Hidden

Date Submitted

DD slash MM slash YYYY

Comments

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

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FEATURED PROCEDURES

Breast Augmentation
Breast Reduction
Breast Lift
Eyelid Surgery (Blepharoplasty)
Tummy Tuck (Abdominoplasty)
Otoplasty (Prominent Ears)
Breast Implant Removal
Male Breast Reduction (Gynaecomastia)

DR ANDRE SAFVAT (MED1155201)

Registered Medical Practitioner, Specialist Plastic Surgeon (specialist registration in Surgery – Plastic surgery).

Locations

Call: (02) 8544 3270
Fax: (02) 8580 4999
E: consult@ethiqueplasticsurgery.com.au

Plastic Surgeon in Miranda
Suite 205a, Level 2, 531-533 Kingsway, Miranda NSW 2228

Plastic Surgeon in Sydney
3/112 Majors Bay Road, Concord NSW 2137

Plastic Surgeon in Bowral
38 Merrigang Street, Bowral NSW 2576

Request a Callback

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Phone*

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Bowral Location

On-site parking is available for all patients

Concord Location

There is 1 hour street parking on “Majors Bay Road”, or on Trafalgar Parade at the adjacent Street.

Miranda Location

There is limited 1 hour street parking on “ Kingsway”. Alternatively, parking can be obtained in Westfield Miranda (no charge for the first 3 hours) which is across the road from our building. The best parking entrance to use is the “Jackson Avenue” entrance which is a short 3-5 minutes walk from our building. For your convenience, there is a drop off area outside our building where patients with limited mobility are able to be dropped off.