Patient RegistrationPatient registrationThis content is password protected. Section A - Your Details Title*MrMrsMissMsMstDr First Name* Surname* Date Of Birth* Gender*MaleFemale Home Address* Suburb* Postcode* Mobile Number Work Number Home Number Email Address* Occupation Medicare card number* Reference No. (no. next to your name)* Pension/HCC Expiry Date DVA No Gold Card (yes/no) YesNo Private Health Insurance Fund: Hospital cover (if none leave blank) Membership No. Please complete if TAC or Workcover Claim No. Date of accident Employer Employer Address Phone Number Insurance Case Manager Case Manager Phone Section B: Next of Kin Name* Relationship to you* Contact Number* Section C: Allergies and medicines List allergies and intolerances to medications List regular medication Section D: Medical History – do you have or have you had a history of the following Surgery (Provide details) Do you suffer from any of the following medical conditions? AsthmaDiabetes – Type 1Diabetes – Type 2Heart TroubleHigh blood pressureEpilepsyBlood Clots / Bleeding DisorderHepatitis/HIVPacemakerAnti Coag Medication Any complications with anesthetics? Lifestyle risk factor information: SmokingIf Yes, how many day/ week AlcoholIf Yes, how many day/ week month Section E: Privacy & Financial Consent We require your consent to collect this information. By signing this form you are agreeing that you have read and understood our Practice Privacy Policy. Your health fund does not cover in room consultations. You will therefore be expected to pay for your consultation on the day. We accpet cheque, EFTPOS, Visa and Mastercard. We do not accept cash, American Express and do not bulk bill. When possible, we will send your Medicare rebate claim electronically on your behalf. Our surgeons are known GAP providers and your GAP payments are required to be paid at least one week prior to surgery to secure your booking. Post operative visits are covered by the GAP payment for a period of up to 6 weeks. Test ordered including X-Rays, blood tests, nerve conduction studies and pathology will incur additional charges. The provider of these servies will bill you seperately. Please sign below to confirm that you have read and understood the above information and you agree to your financial obligations. Signature* Date* Name*