Homepage » Patient Information Form Patient Information Form Please complete all of the fields below as they are required for your consultation.* Mandatory Fields Surname:* Given Names: * Date of Birth: * Sex:MaleFemale Home Address: City: State: Postcode: Mobile number: Work phone number: Email Address: * Department of Veteran Affairs File Number: Health Fund: Member Number: Type of cover: ---Hospital onlyExtras onlyHospital and extras combined Next of Kin: Phone: Contact Address: Medicare Claiming Details Medicare Card Number: - Expiry: For patients under 18yrs old please provide claimant details for Medicare Claimant name: Claimant Date of Birth: Medicare Card Number: - Expiry: Address: Medical History Current Medications: Allergies: Do you take aspirin or blood thinners regularly? YesNo Are you pregnant? YesNo Are you a smoker? YesNo Have you ever had any of the following: Heart Conditions YesNo Bleeding Disorders YesNo Joint replacement YesNo Hepatitis/HIV/Aids YesNo Cancer treatment YesNo Rheumatic Fever YesNo Other conditions that may be relevant:
