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WOMEN Centre
Patient registration

Tell us a bit about yourself

Title

First name

Last name

Date of birth

Occupation

Address

Suburb

State

Postcode

Country

Email

Correspond via email

Upload your photo (optional)

Mobile phone

Work phone (or best contact number)

Home phone (or best contact number)


Next of kin

Name

Relationship

Phone

Health care

Medicare information

Medicare card number

IRN

Valid to

Do you have private health care?

Health Fund

Membership number

Member over 12 months?

Do you have a Health care, Pension or DVA card?

Select card

Card number

Expiry date

Practitioners

Practitioner you are seeing

Do you have a usual GP?

Your usual GP's Name

Practice address

Suburb

State

Postcode

Country

Phone

Do you have a referral?

Referring Doctor's Name

 

Attach referral letters/results (Multiple files allowed)

Medical correspondence

Are there other Medical Practitioners you would like correspondence to be sent to apart from your referring Doctor and usual GP?

Practitioner 1 - Details

Practitioner 1 - Name

Phone

Practice address

Suburb

State

Postcode

Country

Your history

Do you have any current or prior Illnesses/Medical conditions?

Please describe your current or prior illnesses/medical Conditions

Have you had any previous Operations/Surgery?

Please describe your previous operations/surgery

Do you have any Allergies/Reactions?

Please describe your Allergies/Reactions

Do you have any Social history that might affect your medical treatment?

Please describe your social history

Is there any other information that may affect your medical treatment?

Please describe

Pregnancies

Outcome of pregnancies

Number of cigarettes a day

Number of std drinks a day

Medication

Are you on any current medication?

Medication 1

Amount and number of times per day

Are you on medication but unsure of the name?

Please describe the current medication you are on

Thank you

  • Please note that the information supplied is confidential and patient privacy is always maintained.
  • I declare that all information written on the above form is true to the best of my knowledge.
  • Images may be captured and stored on your medical records during clinical examination and/or colposcopy examination to aide in documentation and treatment progress of clinical problems.
  • All images are de-identified. Should you not wish any images to be captured, please inform us.
  • Medical students may be present during examinations, if you do not wish this, please inform your doctor.
  • I consent for my medical information to be forwarded to other health professionals if necessary.