The Urology Rooms - Patient Registration

Patient Details

Title

First Name

Known as

Last Name

Date Of Birth

Occupation

Email

Mobile Phone

Home Phone

Address

Suburb

State

Postcode

Next of Kin

Next of Kin Name

Emergency Contact (Mobile)

Relationship to Patient

Medicare and Insurance

Medicare No.

Ref No: (next to name)

Expiry Date

Do you have Private Health Insurance?

Yes

No

Name of Private Insurance Fund

Membership Number

Do you have Hospital Cover?

Yes

No

Do you have a DVA card?

Yes

No

DVA Number (if applicable)

DVA Card Colour

Referrer Details

Referring Doctor/GP

Clinic or Practice Name

Is this your usual Doctor / GP?

Yes

No

Usual Doctor/GP (if different)

Clinic or Practice Name

Medical Information & History

Are you taking any medications that thin the blood (if so, please list)

Yes

No

List of all medications being taken

Do you have any drug allergies?

Yes

No

Please specify your allergies

Do you or have you had any of the following?

Other Medical History

Medications

Previous Operations

Workers Compensation

Is your treatment related to WorkCover or CTP?

Yes

No

Worker's compensation - Employer

Insurance

Claim No.

Final Step

Please upload any relevant files (GP Referral, blood test results, urine test results, imaging report etc.)

Maximum file size: 10MB

Max. file size is 10mb. (Following files only. jpg, jpeg, png , gf, xls, doc, docm, docx, pages, pdf)

Consent

I hearby give my permission for Dr Doeuk to discuss and seek medical information from any medical practitioner, who has referred, treated or will treat me as long as the exchange of information is necessary for my medical treatment.

Full Name

Date

Signature

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