Patient Details

It’s essential that Dr Raja Sawhney know the details of your medical history. Having our patient’s medical history enables us to obtain the necessary information to provide safe and individualised care.

Please note, all the information you give us on this patient history form will remain strictly confidential.

Please fill out the form below, or click to download and print it.

Patient Detail Form

  • DD slash MM slash YYYY
  • Next of Kin

  • General Practitioner

  • Medicare Information

  • Private Health Insurance

  • Supporting Documentation

    Please upload any referrals or supporting documents you may have below.
  • Max. file size: 13 GB.
  • Max. file size: 13 GB.
  • Max. file size: 13 GB.
  • Consent Form

    We require consent to collect personal information about you. Please read this information carefully.

    This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so we may properly asses, diagnose, treat and be proactive in your healthcare needs. This means we will use this information you provide in the following ways:

    - Administrative purposes in running our medical practice.
    - Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
    - Disclosure to others involved in your health care including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors or for medical tests and in the reports or results returned to us following referrals.
    - Disclosure to other doctors in this practice and locums attached to the practice for the purpose of patient care and teaching. Please let us know if you do not want your records accessed for these purposes and we will note accordingly.
    - Disclosure for research and quality assurance activities to improve individual and community healthcare and practice management. You will be informed when such activities are being conducted and given the opportunity to “opt out” of any involvement.
  • DD slash MM slash YYYY
  • Please note: access to your medical records can only be arranged by calling this office for an appointment. A member of staff is required to be present during any access of your medical records.

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