Patient Registration Form Given Names Surname Title —Please choose an option—MrMsMrsDrOther Known As Address Suburb Postcode Contact No Email Date of Birth Medicare No Medicare Ref No (Number next to your name on Medicare card). Medicare Expiry Date Private Health Insurance Private Health Cover Level None / No Private HealthHospital CoverHospital and ExtrasExtra Cover Only Private Health Fund Membership No Health Care Card No Full Pension Card No DVA Details DVA Card Type Not ApplicableGoldWhite DVA Card No Next of Kin Next of Kin Name Relationship Next of Kin Contact No GP Details GP Clinic Name Name of Regular GP Clinic Address Medical Information Do you have diabetes? YesNo Diabetes Type Type 1Type 2 Diabetic Medications Do you have a pacemaker? YesNo If you have a pacemaker, please provide your pacemaker card at your appointment. Have you had a heart attack or coronary angiogram? YesNo Are you under the care of a cardiologist? If so, who? Do you take any of the following medications? WarfarinClopidogrel / Plavix / IscoverDabigatran / PradaxaXarelto / RivaroxabanApixaban / Eliquis Smoking History Do you currently smoke? YesNo Have you ever been a smoker? YesNo When did you quit smoking? Allergies Are you allergic to anything? YesNo Please list your allergies and reactions Referral Upload Upload Referral or Supporting Document Privacy Consent Personal health information is collected by Peninsula Vascular Group for the sole purpose of providing you high quality healthcare. All information is stored securely and protected by privacy laws. Your health information may be provided to additional parties, including health practitioners, specialists and hospitals, only for the purpose of managing your health. I authorise Peninsula Vascular Group to request additional medical records from other healthcare professionals and organisations, and to provide specialist vascular correspondence to these parties when deemed appropriate. Signature / Full Name Date
