MHC

MEDICAL INFORMATION
To give you meaningful advice and to plan for your consultation or surgery, it is helpful for us to obtain information about you.

We treat this information in a private and confidential manner. If you have a specific concern regarding your privacy please let us know. We abide by current Australian Privacy Legislation.

Many of our patients travel from the other side of town, the country, interstate and overseas. Having all of the information available ensures all goes smoothly.

Once submitted this form and its details will be emailed to you for your records. You may also telephone us on + 61 3 9525 9077.

If you are from Australia you will require a referral letter. Any other medical information will be helpful.

Family Details
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Mobile Number*

Area CodePhone Number
E-mail*
Status*

MaleFemaleMarriedSingle
Occupation / Retired*
Self Employed*

YesNo

Financial Details
Private Insurance*

YesNo
Details*
Is this a workcare Claim?*

YesNo
Details*
Medicare Card No.*
Medicare Card Expiry*
Once you have contacted us and provided the above details we can give you an approximate quote for hospital and medical expenses.

PHYSICAL DETAILS:
Height (cms)*
Weight (kgs)*

Your Hernia
Describe the hernia in your own words. There is a diagram present which shows the site and side of your hernia or hernias.
Mark the site of your hernia with an “X”*

REFERRAL
Name, address and phone number of General Practitioner or specialist to contact should additional medical information be required, so that we may report on your progress and aftercare.
Name*

First NameLast NameSuffix
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Patient Signature*

Clear
Date*

MonthDayYear
HOW DID YOU HEAR ABOUT MELBOURNE HERNIA CLINIC?
Please Select*
Should be Empty: