New Patient Registration Form

New Patient Registration Form

Please fill out the form below to register as a new patient.
BGB Better Growing Bodies Healthcare Clinic
Full Name*

First NameMiddle NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth*

DayMonthYear
Date
Gender

FemaleMaleOther
Weight (kg)
Height (cm)
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Medicare Number
Medicare Line Number
Medicare Expiry Date

MonthDayYear
Date
Ethnicity
Medical History and Current Medications
GP Details - Name and suburb
Perioperative patients - Please put the date of your upcoming surgery
DVA Number
DVA Colour Card
Health Fund Name
Health Fund Number
My Health Record- Do you consent to information being shared on your My Health Record?*
Other Health Professional Specialist
Do you smoke?

YesNo
Do you drink alcohol?

YesNo
Do you take Recreational drugs?

YesNo
How many of the above?
iScribe AI Technology-Dr Vohra uses AI based technology for note taking. It is secure and your data is protected.*

Yes I am happy for the Doctor to use this software (your iScribe data is deleted after Doctor has completed his letter.)No I do not consentI would like more information on how my data is used.
BGB Health Care Clinic may charge an out of pocket 'Gap' payment. By signing this form you are consenting to informed financial consent. The Gap fee is not covered by your private health fund. Medicare rebate will be applied and a portion of the payment will be refunded back into your bank account linked with Medicare. Perioperative patients will be bulk billed by Medicare. When signing this form you consent to BGB billing Medicare on your behalf. Should you have any questions about payments please contact us via email on info@drsahilvohra.com.au
Name*

First NameLast Name
Signature*
Should be Empty:

New Patient Registration Form

BGB Better Growing Bodies Healthcare Clinic