NEW PATIENT INFORMATION
Please complete this form before your appointment at ENT Specialist Centre
PERSONAL INFORMATION
Title
Please Select
Prof
Dr
Mr
Mrs
Miss
Other
Full Name (First Name & Surname)
Preferred Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Other
Occupation
Address
Home Phone
Work Phone
Mobile
Email
example@example.com
EMERGENCY CONTACT DETAILS (NEXT OF KIN)
Name
Relationship
Contact
PERSON IN CHARGE OF ACCOUNT
Person in Charge of Account
Myself
Other
If Other, your Date of Birth
DD/MM/YY
Medicare Card Number
Medicare Card Expiry
Medicare Card Ref no
DVA Card Holder?
Please Select
Yes
No
If No, please continue to next section
DVA Card Number
DVA Card Expiry
DVA Card Colour
Pension Card Holder?
Please Select
Yes
No
Pension Card Number
Do you Private Health Insurance?
Please Select
Yes
No
Private Health Fund Name
Private Health Fund Member Number
MEDICAL INFORMATION
GP Name
GP Phone
GP Address
Dentist Name
Dentist Phone
Are there any other doctors/allied health workers you would like us to send your letters/results to?
Please Select
Yes
No
Please provide their details
Are you currently on any medication?
Please Select
Yes
No
Please list medication
Do you have any known allergies?
Please Select
Yes
No
Please list allergies
Do you have diabetes, kidney problems or hypertension?
Please Select
Yes
No
Do you identify as being Aboriginal or Torres Straight Islander?
Please Select
Yes
No
Do you consent to SMS contact/appointment reminders from ENT Specialist Centre?
Please Select
Yes
No
Patient signature
Date
/
Month
/
Day
Year
Date
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