Patient Information

You are invited to provide the information requested below to assit us in streamlining your case handling.

1. YOUR DETAILS

Name
Date of Birth
Email
Phone Numbers
Street Address
Suburb and State
Postal Address (if different from above)
Suburb and State

2. NEXT OF KIN

Name
Street Address (if different to above)
Suburb and State
Relationship
Contact Numbers

3. MEDICARE AND HEALTH FUND

Medicare
Private Health Fund

4. FAMILY / REFERRING DOCTOR

Family Doctor
Referring Doctor
Would you allow Professor Stricker to use your clinical information for research purposes (confidentiality assured)

5. ALLERGIES AND DRUGS

Please list any allergies you have and any drugs you cannot take. If you have no allergies please write ‘no allergies’.

6.MEDICATIONS

Please list any medications you take and how often (e.g. twice daily) and the dosage

7. PREVIOUS OPERATIONS

Please list any medications you take and how often (e.g. twice daily) and the dosage

8. PRIVACY

I have read the privacy policies I agree to allow Professor Phillip Stricker to access all relevant information regarding my medical condition. I agree that Professor Stricker may be required to forward information about my medical condition or history to other health care providers. I understand that to provide the highest medical care my clinical records may be accessed or reviewed by staff at PRofessor Phillip Stricker's practice. *

Key aspects

From diagnosis and treatment to rehabilitation and research, I believe my highly experienced team and I bring a multifaceted approach to understanding and helping our patients. A summary of these key aspects of that approach is available here in PDF format. If you are suffering from prostate cancer or have reason to believe you might be, you are welcome to contact us or, intially, complete our comprehensive second opinion form.