NEW PATIENT REGISTRATION

Please note: items marked * indicate mandatory fields.

Personal Details

Title

First name

Last name

Preferred name

Date of birth

Contact number

Contact Details

Address

Suburb

State

Postcode

Home Phone

Mobile phone

Preferred Contact Method

Memberships

Medicare Number

Medicare IRN

Medicare Expiry (Month)

Medicare Expiry (Year)

Private Health insurance

Yes

Private Health Fund Name

Private Health Fund Membership Number

Are you a member of the Department of Veterans Affairs (DVA)?

Yes

Department of Veterans Affairs (DVA) Member Number

DVA Card Level

Do you require DVA transport booked for you?

Yes

Emergency contact

Partner Name

Partner Phone

Next of kin Name

Next of kin Phone

Relationship to next of kin

Medical Information

Referring Doctor Name

Referring Doctor Phone

Medical History

Yes - I do have relevant medical history, detailed below

No - I do not have relevant medical history

Existing, diagnosed conditions

Previous operations

Current medications

Current Vitamins or Dietary Supplements

Allergic reactions

Specialist details

If there are any other specialists that require clinical information, please fill the information below.

Specialist Name

Speciality

Specialist Medical Practice Name

Specialist Phone

Consent to release medical information

I give my consent to Sydney Vein Specialist, or their agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care.

I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Sydney Vein Specialist, or their agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010.

For more information view our Patient Information Privacy Statement on this website.

Yes, I consent to the above.