Patient Registration Form Please enable JavaScript in your browser to complete this form.TitleName *FirstLastPreferred Name to be addressed byDate of Birth *Residential Address *Postal Address (if different from above)Best contact phone number *Additional phone numbers eg home, work, mobileEmail *Emergency ContactMedicare Number *Medicare patient ID number (number in front of your name on Medicare card) *Medicare card expiry date *Do you have private health insurance? If yes, please continue to fill all your membership details below. *Please chooseYesNoFund NamePolicy Holder's NameMembership NumberPatient ID number (number on card)Have you been in this health fund for more than 12 months?YesNoLevel of insurance coverCombinedHospital onlyExtras onlyDVA card number (if applicable)Do you give financial consent for your treatment? (Please read description below before giving your choice) *YesNoPayment of consultation is required on date of service. I understand there is a prepayment for further medical treatment and is payable two weeks in advance of procedures. A final itemised account will be issued upon completion of any procedure. Accounts fall due immediately on completion of procedure. If it is not finalised promptly, the debt will be passed on for collection. The patient will be liable for all expenses, costs and/or disbursements incurred in recovering any overdue monies, including debt collection fees, solicitor's fees and legal costs on a full indemnity basis. I consent to verification of Medicare card details. For no gap claims and Medicare bulk billing, I assign my benefit right to the Practitioner who rendered the service. If you click 'no' - please note this means we do not have the ability to submit your Medicare claim for your consult, and you wil be required to claim this manually wtih Medicare yourself. Name of family doctor (GP) and suburb of practiceName of dentist and suburb of practicePlease check any medical conditions which you have been diagnosed withAsthmaHeart problemsLow or high blood pressureLung or chest problemsEpilepsy/seizures/faintingLiver disease, Hepatitis B, Hepatitis CKidney diseaseBleeding disorders (or family history)Anaemia or iron deficiencyDiabetes or blood sugar anomaliesThyroid diseaseOsteoporosis or bone diseaseHIV/AIDSDo you have any allergies? *YesNoPlease list allergiesPlease list all medications taken regularly as well as those taken as required. Please include any vitamins, supplements or herbal remedies.Are you a smoker?YesNoEx smokerHow much alcohol do you consume a week?I very rarely drink alcoholLess than five standard drinksLess than ten standard drinksMore than ten standard drinksI do not drink alcoholOccupationPlease write any additional information regarding your medical history which you feel is relevantEmailSubmit