New Patient Registration

Note: fields marked * are required.

Personal Details

Title

First Name *

Last Name *

Preferred Name

Occupation

Date of Birth *

Contact Details

Address *

Suburb *

State *

Postcode *

Email Address *

Home Phone

Work Phone

Mobile Phone *

Preferred contact method *

Memberships

Medicare Number (10 Digits) *

Medicare IRN (1 digit next to cardholder's name) *

Medicare Expiry Date (Valid To) *

Private Health Fund Name

Private Health Fund Number

Emergency Contact

Next of kin name

Relationship to next of kin

Next of kin phone

Medical information

Referring Doctor Name

Referring Doctor Address

Referring Doctor Suburb

Referring Doctor State

Referring Doctor Postcode

General Practitioner Name

General Practitioner Address

General Practitioner Suburb

General Practitioner State

General Practitioner Postcode

Medical History *
Yes – I do have relevant medical history detailed below.
No – I do not have relevant medical history.

Existing, diagnosed conditions

Previous operations

Other

Consent to release medical information

I give my consent to Dr Ben Green, or his 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 Dr Ben Green, or his agents and advisors, as my be requested. This is in line with the National Privacy Act updated 1st November 2010.

Consent *
Yes I consent to the above.

Prove you're not a robot *

New Patient Registration

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