Patient Registration | Surgical Health Specialists

Personal Details

Name*

Prefix First Last

Preferred Name

Occupation

Marital status

Languages

Date of Birth*

dd/mm/yyyy

Contact Details

Address

Street Address Suburb Post Code

Email*

Mobile*

Emergency Contact Name*

First Last

Emergency Contact Phone*

Relationship

Billing and Insurance

Medicare Number

Medicare expiry date

Private Health Fund Name

Private Health Fund Number

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

Yes
No

Medical Information

Referring Doctor Name

Prefix First Last

Referring Doctor Phone

Add another Specialist's Details?

Yes
No

Specialist Name

Prefix First Last

Practice Name

Phone

Speciality

Family history

Mother

Father

Sibling

Children

Additional Information

Consent to release medical information

Yes
No

I give my consent to Dr Edwina Moore / Mr Vladimir Bolshinsky, 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 Dr Edwina Moore / Mr Vladimir Bolshinsky, or their agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010.

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Personal Details

Contact Details

Billing and Insurance

Medical Information

Other Medical Problems

Family history

Consent to release medical information