New Patient Registration - Central Dermatology Clinic

Title

First Name

Last Name

Preferred Name

Occupation

Date Of Birth

Date

Year

Gender

Male

Female

Address

Suburb

State

Postcode

Email Address

Home Phone

Please enter phone number with area code included. No spaces please. eg. 0298765432

Work Phone

Please enter phone number with area code included. No spaces please. eg. 0298765432

Mobile Phone

Please enter your full mobile number. No spaces please. eg. 0412345678

Preferred Contact Method

Memberships Medicare Number

10 Digits Medicare IRN

1 digit next to cardholder’s name

Medicare Expiry (MM/YY)

Date

Year

Private Health Fund Name

eg. HCF, NIB, Bupa

Private Health Fund Membership Number

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

Yes

No

Partner name

In case of Emergency

Partner Phone

Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432

Next of kin Name

Relationship to next of kin

Next of kin Name Phone

Referring Doctor Name

For Medical Information

Referring Doctor Phone

Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432

Medical History

Yes – I do have relevant medical history, detailed below

No – I do not have relevant medical history

Specialist Name

If there are any other specialists that require clinical information

Speciality

Specialist Medical Practice Name

Specialist Phone

Consent to release medical information

Consent

Yes, I consent to the above.

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