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:
Former Name / Maiden Name
Date of birth (dd/mm/yyyy)
Home Phone Number
Mobile Phone Number
GP Contact details
Health Insurance Fund
Work Cover, Defence Personnel, Third Party or 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?
Admission Date (dd/mm/yyyy)
Length of Stay
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
Estimated theatre time:
Name of Facility:
Date of Admission to other facility (dd/mm/yyyy)
Date Swabs taken (dd/mm/yyyy)
Is a preadmissions appointment required?
Additional pre-admission information
Are there pharmacy scripts associated with this booking?
Initiate on admission
Is Patient Day of Surgery Admission?
If no, why?
Have swabs been requested?
PLEASE INDICATE FROM THE FOLLOWING WHERE THE PROCEDURE OR INTERVENTION IS TO OCCUR:
Mater Clinic Theatres
Cardiac Catheter Lab
Pagent Family Obstetric Theatre
Other procedure or intervention location:
Procedure or intervention date (dd/mm/yyyy)
Is an anaesthetist required?
Is ICU bed required following procedure?
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.....