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Admission Forms

Admission forms are provided to ensure that relevant medical, personal, and referral information is available ahead of your appointment or procedure. Completing these forms in advance helps streamline the admission process and allows your care team to focus on your clinical needs on the day. All information is handled confidentially and in accordance with privacy requirements.

Patient Details

Full Name:*

Date of Birth: *

day

month

year

Gender:*

Male

Female

Other

Address:*

Phone (home):*

Mobile: *

Email:*

Emergency Contact Name & Relationship:

Emergency Contact Phone:

Medical History

Do you have any current medical conditions?*

Yes

If yes, please specify:

Past surgeries or hospital admissions:*

Current medications (including dosage): *

Allergies (medications, food, environmental): *

Lifestyle & Risk Factors

Do you smoke?

Yes

If yes, how much?

Do you consume alcohol?

Yes

If yes, how much?

Do you exercise regularly?

Yes

Details:

Dietary habits:*

Sleep patterns / stress levels:*

Symptoms & Concerns

Current symptoms:

Palpitations

Shortness of breath

Fatigue

Dizziness

Other

Duration of symptoms:*

Frequency / pattern of symptoms:*

Any known triggers?*

Referral Information

Referring Doctor Name:*

Referring Clinic / Practice: *

Reason for referral / clinical question:*

Attach any previous test results, imaging, or letters:

Yes

Consent & Privacy

I consent to treatment and procedures recommended by Dr Louise Segan and her team.*

Yes

I acknowledge that my personal health information will be stored securely in accordance with privacy regulations. *

Yes

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Learn More About Dr Segan

To learn more about Dr Louise Segan’s clinical background and approach to care, please visit the About page.
Details on training, research, and hospital appointments are available there.

ABOUT

Home
About
Clinical Services
Admission Forms
Research
Patient Information
Locations
Contact