Patient Registration Patient Registration form Name Mr.Mrs.MissMs.Dr.Prof.Other Prefix First Last Date of Birth: Address Street Address Suburb Post code State Home phone: Mobile phone:* Email:* Insurance DetailsDo you have a valid medicare card?* Yes No Medicare no:* Ref no:* Exp. date: Private Health Insurance* Yes No Fund name: Fund no: Dept. Veteran Affairs card no: White Gold Expiry date: Concession CardIf you have a valid pension card please upload photos below or present this to reception to verify. For Telehealth appointments, please upload or send a photo of both sides of your pension card to info@drvascular.com.au. Valid and verified pension card holders will receive a discount. (Not valid for seniors cards).Upload photos of Concession cardPlease ensure you upload photos of both the back and front of you card. Drop files here or Select files Max. file size: 128 MB. General Practitioner's details:Name: Practice name: AddressReferring Dr:Doctor: GP Specialist Other Name of referrer: Next of Kin details:Name: Relationship to you: Contact no. : Are you happy for Dr Robinson to call your next of kin after any operation? Yes No Medical QuestionnaireMedications:Please list all current medications including herbal or vitamin preparations:Allergies - do you have any know allergies? Yes no AllergiesMultidisciplinary meetings:I consent to my case being discussed in multidisciplinary meetings as deemed appropriate by Dr Robinson: Yes No Photography consent:Video and still images are occasionally taken during operative procedures. These become part of your confidential medical records. We also would like to ask you for permission to use these photos for educational purposes in addition to their use as part of your medical care. All images used for purposes other than medical records are de-identified. Names are not used and as far as possible identifying factors are masked.Do you consent to these images being used for the purpose of (1) teaching, (2) publication in medical journals, (3) educating patients? Yes No CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ
