www.drganeshsurgery.au - Registration Form

Registration Form
Title*
Name*

First NameLast Name
Preferred Name
Address*
Address, Suburb, State, Postcode
Date of Birth

MonthDayYear
Mobile Phone Number*
Home Phone Number
Work Phone Number
Email Address*
example@example.com
Preferred Contact Method *
Medicare Number ( 10 Digits)
Medicare Reference (Number next to your name)
Medicare Expiry Date

MonthDayYear
Date
Private Health Fund Name
Private Health Fund Number
Referring Doctor Name
General Practitioner Name
If different to above
Next of kin name
Relationship to next of kin
Next of kin phone Number
Medical History
*

Yes – I do have relevant medical history detailed belowNo – I do not have relevant medical history
Existing, diagnosed conditions
Select following*

Heart DiseaseLung DiseaseRenal DiseaseRheumatoid DiseasePrevious CancerOther
If "Other" Please Explain?*
Previous operations
Consent
Consent to release medical information*

I give my consent to Dr. Ganesh or his staff, 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. Ganesh, or his agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010.
Financial consent*

I understand that medical expenses (including any gap payments) incurred as a result of consultation or surgical procedure with Dr. Ganesh or his staff are my responsibility. If requested, I will pay my account in full and take full responsibility for claiming costs from the appropriate private health fund. All accounts are payable within 30 days of receipt. Please check with reception staff to confirm the procedures costs of gap payments that may be incurred.
Signature*
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Registration Form

Medical History

Consent