Dr Grahame Smith

Patient Registration Form

PATIENT DETAILS

First Name

Last Name

Date of Birth

Country of birth

Gender

MaleFemaleOther

House number and Street *

Suburb *

State *

Postcode

MEDICARE number

Patient #

Medicare expirymm/yy

English is a Second Language

noyes

Ethnicity

ATSI

AboriginalTorres Strait IslanderBothNone of the Above

Is an interpreter required

noyes

Language used at home

PARENT or GARDIAN DETAILS

Parent title

Parent First name

Parent Last name

Relationship to patient

Best contact number

Parent Medicare number

Medicare expirymm/yy

Address

Home Phone

Mobile Phone

Work Phone

Email

Would you like a copy of the letter sent to your doctor emailed to you?

yesno

This will be a PDF file and not encrypted, so will have a small risk to patient privacy, similar to if the correspondence was posted.

SECOND NEXT OF KIN

First Name

Last name

Address

Home Phone

Mobile Phone

Email

Work Phone

OTHER CONTACT DETAILS

Is the next of Kin same as your emergency (if yes, you do not need to fill this section)

YesNo

Next of Kin - Name

Next of kin - Email

Next of kin Home Phone

Next of kin - Mobile Phone

Best way to contact your next of Kin

Home PhMobile PhWork Ph

REFERRING DOCTOR TO US

Referring Doctor’s Name

Address

Family Doctor/ Regular General Practitioner Name (if different to referring doctor)

Address

If you use Alias please write the Alias name & surname

please upload your referral here (pdf, word or text preferred)

Browse

Referral sent *

UploadedFaxed to 02 8076 3887Emailed to secretary@urology.com.auI will bring a paper copy

PRIVATE HEALTH INSURANCE

Do you have private Medical insurance

YesNo

Provider

Membership No.

Expiry

PENSION / HCC/DVA Card

Do you have an aged pension card, healthcare card or a DVA card

YesNo

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

DVA No.

PATIENT HISTORY

MEDICATIONSseparate by a comma

Allergiesseparate by a comma

Family history of illness

Is there a family history of bleeding

Other illnessDoes your child have any other illness ?

Other operationsHas your child had other operations

Term baby (38 to 40 weeks)

yesno

Weeks gestation

Birth weight

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

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Today's Date

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