Patient Registration Form Title: First Name: Family Name: Preferred Name: Date of Birth: Gender: Residential Address: Home Telephone Number: Mobile Number: Work Number: Email Address: Medicare Number: Number next to your name on the Medicare Card: Expiry Date: Please check if applicable: Pension Card Health Care Card Card Number: Expiry Date: Number: Do you have a Department of Veterans’ Affairs card? Yes No Membership Number: Card Colour: Gold White Emergency Contact (Next of Kin): Name: Relationship to Patient: Contact Telephone Number: Account Holder (for patients under 18): For Medicare Claiming Purposes: Date of Birth of Account Holder: Number next to your name on the Medicare Card: Name of General Practitioner (GP) If you have been referred by someone other than your General Practitioner: Please include clinic name as some GPs work at various locations. Any known allergies and / or are you sensitive to any medications, dressings or Latex? Melanoma Yes No Additional Information (Melanoma) Are you on any blood thinning agents? Do any of these conditions apply? Skin Cancer (melanoma, BCC, SCC) Yes No Additional Information (Skin Cancer (melanoma, BCC, SCC)) Bleeding Disorder Yes No Additional Information (Bleeding Disorder) Diabetes requiring Insulin or Tablets. Yes No Additional Information (Diabetes requiring Insulin or Tablets.) Currently Pregnant Yes No Additional Information (Currently Pregnant) Current Anticoagulants (ie Warfarin, Plavix, Iscover, Pradaxa) Yes No Additional Information (Current Anticoagulants (ie Warfarin, Plavix, Iscover, Pradaxa)) Cardiac Pacemaker or Heart Valve Replacement Yes No Additional Information (Cardiac Pacemaker or Heart Valve Replacement) Allergies Yes No Additional Information (Allergies) reCAPTCHA If you are human, leave this field blank. Submit
