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New Patient Registration

Please note: items marked * indicate mandatory fields.

Personal details

Title *

First Name *

Last Name *

Preferred name

Occupation

Date of Birth *

Day

Month

Year

Contact details

Address *

Suburb *

State *

Postcode *

Email *

Home Phone

Please enter phone number with area code included. No spaces please. eg. 0298765432

Work Phone

Please enter phone number with area code included. No spaces please. eg. 0298765432

Mobile Phone

Please enter your full mobile number. No spaces please. eg. 0412345678

Preferred Contact Method *

Memberships

Medicare Number

10 Digits

Medicare IRN

1 digit next to cardholder's name

Medicare Expiry Date (Valid To)

Day

Month

Year

Private Health Fund Name

eg. HCF, NIB, Bupa

Private Health Fund Membership Number

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

Yes

No

Department of Veterans Affairs (DVA) Member Number

DVA Card Level

Do you require DVA transport booked for you?

Yes

No

Workcover

Is this an injury associated with a WorkCover claim? *

Yes

No

WorkCover Claim Number *

Employer Name *

Emergency contact

Partner Name

Next of kin Name

Partner Phone

Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432

Next of kin Phone

Relationship to next of kin

Medical Information

Referring Doctor Name

Referring Doctor Phone

Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432

Medical History *

Yes – I do have relevant medical history, detailed below

No – I do not have relevant medical history

Are you a diabetic?

Yes

No

If you a diabetic, are you also insulin dependent?

Yes

No

Existing, diagnosed conditions

Previous operations

Current Medications

Including over the counter medications

Current Vitamins or Dietary Supplements

Allergic reactions

Drugs or other causes

If there are any other specialists that require clinical information, please fill the information below.

Specialist details

Specialist Name

Speciality

Specialist Medical Practice Name

Specialist Phone

Consent to release medical information

I give my consent to Dr Trevor Gervais, 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 Trevor Gervais, or their agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010.

For more information view our Patient Information Privacy Statement on this website.

Consent *

Yes, I consent to the above.

Leave this field blank

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