2020NOW Patient Registration Form

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Please ensure your details are correct before you click "submit". If you have any questions, please ask at the front desk.

Patient Details

Title *

Mrs

Miss

Prof

Surname *

First Name *

Middle Name

Preferred Name

Date of Birth *

YYYY

Street Address *

Suburb *

Postcode *

Mobile phone number *

Please enter 10 digits with no spaces.

Home phone number

Email address *

Emergency contact / Next of Kin *

Please enter the name of your emergency contact and their relationship to you.

Emergency contact / Next of Kin phone number *

Please enter the contact number corresponding to your above response.

Medicare Details

Medicare Card Number *

Please enter 10 digits with no spaces

Medicare Card Reference Number *

Please enter the number found in front of your name on the Medicare card (eg. 1)

Medicare Card Expiry Date *

Please enter the expiry date of your Medicare card in MM/YY format

Private Health Insurance Details

Please leave blank if you are not insured

Name of Health Insurance Fund

Membership number

Type of Cover (optional)

Pension Card Details

Please note we do not accept Commonwealth Seniors Health Cards. If you are unsure, please ask at the front desk.

Type of Benefit

EG Aged Pension/Sickness Benefits

Customer Reference Number

This is the number found on your pension card

Pension/Health Care Card Expiry Date

YYYY

Veterans' Affairs Card Details

Department of Veterans' Affairs Card Number

Level of Cover

Gold

White

Clear selection

Other Medical Care Information

Treating Optometrist

Please enter the name and address of your treating optometrist

Treating General Practitioner

Please enter the name and address of your treating GP.

Are there any other doctors involved in your care?

EG Cardiac Specialists

Yes

Clear selection

If yes, please give their name and address

Are you diabetic? *

Yes

If you are diabetic, are you:

Diet Controlled

On Medication - semaglutide (Ozempic) or liraglutide (Saxenda or Victoza)

On Medication - other

Insulin Dependent

Do you take:

Blood thinners

Prostate Medication

None of the above

Please list any forms of medications you take, amount and frequency of dosage

Please list any allergies or sensitivities

Please list any previous surgical procedures and year of surgery

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