| Clinic #*
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Are you a machine? If not please enter nothing in here:
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Please type in your unique 5-digit clinic ID number that you were provided with when you made your appointment.
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| Doctor*
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| Family Name:*
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| Given Names:*
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| Date of Birth:*
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| Title
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| Home Address:*
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| Post code*
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| Postal Address (if different):
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| Post code
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| Telephone home:*
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| Telephone work:
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| Mobile:
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| Email:*
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| Usual family Doctor:
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| Referring Doctor:
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| Occupation:*
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| Medical Insurer:
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If your appointment relates to an ACC injury we require the following:
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| ACC claim number
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| Date of injury
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If patient is a dependant child:
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| Name of parent:
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| How did you come to hear of Da Vinci Clinic, Mr Adam Bialostocki or Mr Brandon Adams
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I'm happy to receive emails from Da Vinci Clinic
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Following your consultation, a letter is usually sent to your Doctor to keep him/her informed.
If for any reason you would prefer this letter NOT to be sent, please tick the box below.
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Please don't send letter
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- For some sensitive examinations, a Chaperone will be present.
- Any unpaid accounts will incur late payment fees. If your account is sent to a debt collection agency, these collection costs will be added to the debt and will become the responsibility of the debtor.
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Click here to read the terms & conditions for Da Vinci Clinci for your reference.
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| I agree to the terms and conditions of Da Vinci Clinic*
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| Current Medications:
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| Previous Surgery:
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| Drug allergies:
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| Are you a smoker?*
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| Do you regularly take any of the following:
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| Do you have or have you ever had any of the following:
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| If you have come for a Cosmetic Consultation, what aspect of your appearance would you like to discuss today?
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