Please note: items marked * indicate mandatory fields. Personal details Title * - Select -MrMrsMissMsDr First Name * Last Name * Preferred name Occupation Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year19241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Contact details Address * Suburb * State * - Select -ACTNSWVICSAQLDNTWATAS Postcode * Email * Home Phone Please enter phone number with area code included. No spaces please. eg. 0298765432 Work Phone Please enter phone number with area code included. No spaces please. eg. 0298765432 Mobile Phone Please enter your full mobile number. No spaces please. eg. 0412345678 Father’s Mobile Mother’s Mobile Preferred Contact Method * - Select -EmailHome PhoneWork PhoneMobile Phone Memberships Medicare Number 10 Digits Medicare IRN 1 digit next to cardholder's name Medicare Expiry (MM/YY) Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20242025202620272028202920302031203220332034 Private Health Fund Name eg. HCF, NIB, Bupa Private Health Fund Membership Number Are you a member of the Department of Veterans Affairs (DVA)? * Yes No Department of Veterans Affairs (DVA) Member Number DVA Card Level - None -GoldWhiteOrange Do you require DVA transport booked for you? Yes No Parent/Guardian’s Details Father’s Name Father’s Address Suburb State - None -ACTNSWVICSAQLDNTWATAS Postcode Father’s Date of Birth Mother’s Name Mother’s Address Suburb State - None -ACTNSWVICSAQLDNTWATAS Postcode Mother’s Date of Birth Medical Information Referring Doctor Name Referring Doctor Phone Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432 Is referring Doctor the same as regular family Doctor? * Yes No Name of Family Doctor Address Suburb State - None -ACTNSWVICSAQLDNTWATAS Postcode Phone Past History Details Was baby premature? * Yes No Weeks? Any known allergies? Any serious illnesses? Any operations? Any medications? (on now or periodic)? Any family history of problems with anaesthetics or operations? * Yes No Details? Any family history patient problems with bleeding? * Yes No Details? Any other relevant information? Consent to release medical information I give my consent to Total Paediatric Surgery, or their agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Total Paediatric Surgery, or their agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. For more information view our Patient Information Privacy Statement on this website. Consent * Yes, I consent to the above. Continue
