(02) 4600 5640 reception@drsv.com.au

Associate Professor Sameer Viswanathan












    Next of KIN



    Medicare - Private Health Details









    If the patient is your child & you would like the claim submitted to Medicare please provide your details






    Workers Compensation










    Informed Financial Consent

    Please read and sign (to be signed by parent or guardian if patient under 18 years):

    • Permission is given to release the medical history to the family doctor, treating specialist and insurance company. Under Australian Law, Privacy Act 1988, patient information will not be released to other third parties (except the above mentioned) without patient written consent. For further information please refer to Privacy Act 1988 at www.comlaw.gov.au

    • Information may be used for quality assurance, research & teaching but will not disclose personal identification.

    • Please be aware that any outstanding amounts requiring debt recovery will incur debt recovery fees and any legal costs involved.

    Medical History


    KneeHipShoulderAnkleFeetOther


    i-Med RadiologyLumus ImagingSouth West RadiologySouth East RadiologyOran Park RadiologyHarbour ImagingXplore RadiologyPRP ImagingSpectrumNoneOther


    AsthmaDifficulties with anaestheticHypertensionEpilepsyHigh Blood pressureCancerDiabetesDepressionStrokeBleeding disorderNone








    AspirinCartiaWarfarinPlavixEliquisFish OilGlucosamineNoneOther



    YesNo


    DailyWeeklyMonthlyOccasionallyNever

    I have carefully read the above and certify that information I have given is correct to the best of my ability.



    For all enquiries

    Campbelltown

    Suite 12, Level 1
    Campbelltown Private Hospital
    42 Parkside Crescent, Campbelltown NSW 2560

    Liverpool

    Suite 7, Level 4
    Sydney South West Private Hospital
    26-40 Bigge Street
    Liverpool 2170

    Gregory Hills

    Suite 26, Floor 2,
    13 Digitaria Drive
    Gregory Hills