Northside Theatre Online Booking Amendment Form
This form is only to be used to amend a pre-existing booking
Please advise of the details to be amended and a reason:
Patient Details
Admission campus
Northside
Title
Mr
Mrs
Miss
Ms
Other
Other:
Surname
First names
Preferred name
Former Name / Maiden Name
Date of birth (dd/mm/yyyy)
Gender
Male
Female
Intersex
Street Address
Suburb
Postcode
Email Address
Home Phone Number
Mobile Phone Number
GP Name
GP Contact details
Health Insurance Fund
Membership #
Veteran Affairs
Gold Card
White Card
Approved for
days
Insurance Co.
Work Cover, Defence Personnel, Third Party or Self Insured?
Work Cover
Defence Personnel
Third Party
Self Insured
Claim Number – WorkCover, Defence or Third Party:
Case Manager - WorkCover, Defence or Third Party:
DVA Card Number and Expiry - if applicable:
Medicare number (including order)
Medicare expiry date (mm/yyyy)
Pension Card Number and Expiry - if applicable:
Has the patient been to the Mater before?
No
Yes
Admission Details
Admission Type
Surgical
Medical
Admitting Doctor
Treating Doctor(s)
Admission Date (dd/mm/yyyy)
Length of Stay
Day Only
Overnight - 1 day
Overnight - 2 days
Overnight - 3 days
Overnight - 4 days
Overnight - 5 days
Overnight - 6 days
Overnight - 7 days
Overnight - 8 days
Overnight - 9 days
Overnight - 10 days
Overnight - 11 days
Overnight - 12 days
Diagnosis
Treatment
Estimated theatre time:
TRANSFER FROM:
Name of Facility:
Date of Admission to other facility (dd/mm/yyyy)
Contact Ph
Date Swabs taken (dd/mm/yyyy)
Is a preadmissions appointment required?
No
Yes
Additional pre-admission information
Are there pharmacy scripts associated with this booking?
No
Yes
Initiate on admission
Is Patient Day of Surgery Admission?
Yes
No
If no, why?
Have swabs been requested?
No
Yes
Procedure Details
PLEASE INDICATE FROM THE FOLLOWING WHERE THE PROCEDURE OR INTERVENTION IS TO OCCUR:
Mater Clinic Theatres
Endoscopy Suite
Nolan Theatres
Cardiac Catheter Lab
Pagent Family Obstetric Theatre
other
Other procedure or intervention location:
Procedure or intervention date (dd/mm/yyyy)
Is an anaesthetist required?
Yes
No
Anaesthetic type
General Anaesthetic
Local Anaesthetic
Spinal
Assisted Local
Other
Primary MBSN
Other MBSN
Is ICU bed required following procedure?
No
Yes
Required for
days
Instruments / Prosthesis / High Cost Consumables / Equipment / Special Instructions
Thank you for submitting your form.
Redirecting you to the clinical consent form or approval letter upload page.....
