Please note: items marked * indicate mandatory fields. Personal details Title * - Select -MrMrsMissMsDr First Name * Last Name * Preferred name Occupation * Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Relationship status * Single De Facto Married Divorced Widowed Contact details Address * Suburb * State * - Select -ACTNSWNTQLDSATASVICWA 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 * - Select -EmailHome PhoneWork PhoneMobile Phone Email consent * Yes, I consent to correspondence via my provided email address. No, I do not consent to correspondence via my provided email address. SMS consent * Yes, I consent to appointment reminders via SMS. No, I do not consent to appointment reminders via SMS. Memberships Do you have a Medicare card? * Yes No Medicare Number * 10 Digits Medicare IRN * 1 digit next to cardholder's name Medicare Expiry Date * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20242025202620272028202920302031203220332034 Valid To Are you a member of a Private Health Fund? * Yes No Private Health Fund Name (Hospital cover) * eg. HCF, NIB, Bupa Private Health Fund Number (Hospital cover) * Private Health Fund Name (Extras cover) Private Health Fund Number (Extras cover) Are you a member of the Department of Veterans Affairs (DVA)? * Yes No Department of Veterans Affairs (DVA) Member Number * DVA Card Level * - Select -GoldWhiteOrange DVA Expiry Date * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20242025202620272028202920302031203220332034 Valid To Do you require DVA transport booked for you? * Yes No Do you have an aged pension card? * Yes No Aged pension number * Aged pension Expiry Date * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20242025202620272028202920302031203220332034 Valid To Emergency contact Partner Name Partner Phone Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432 Next of kin Name Next of kin Phone Next of kin - relationship to Patient Medical Information Who referred you? * General Practitioner Specialist Doctor GP Name * GP Address * GP Phone * Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432 Specialist Name * Specialist Address * Specialist Phone * Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432 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 + More Consent for release of Medical Information I give my consent to Vascular Health Group, 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 Vascular Health Group, 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. Consent - Medical Information * Yes, I consent for release of Medical Information. Consent for Appointment Contact I give my consent to Vascular Health Group to speak with a person I nominate (eg: family member or friend) in relation to appointments. * Consent - Appointment Contact * Yes, I consent for Appointment Contact. No, I do not consent for Appointment Contact. Appointment Contact Name * Consent for Photography Photography for my care * I give my consent to Vascular Health Group to take clinical photographs to assist in my care and documentation of before and after treatment. Photography for my care * Yes, I consent for photography for my care. No, I do not consent for photography for my care. Photography for educational purposes * I give my consent to Vascular Health Group to take clinical photographs (de-identified) that may be used for educational purposes. Photography for educational purposes * Yes, I consent for photography for educational purposes. No, I do not consent for photography for educational purposes. How did you hear about us? How did you hear about us? * Search Engine Online Advertising Social Media Personal Recommendation Specialist Doctor or GP Other Please specify how you heard about us * Interpreter Do you require an interpreter? * Yes No Interpreter Language * Continue
