Patient Registration Form - please complete as soon as possible

The form may be partially completed, saved, and completed at a later time.

Payment for all rooms consultations is on the day, please see our website FAQ for fee information.

We are able to submit your rebate claim direct to Medicare electronically for you,
as long as you have a current written referral.

Patient details

**If Other, please give details

First Name *

Middle Name (if any)

Last Name *

Known as (if different from first name)

Date of Birth *

Gender *

FemaleMaleIntersex/OtherNot Stated

Are you retired? *

YesNo

Current / most recent occupation *

Have you ever had COVID?

Have you ever been diagnosed with COVID? *

YesNo

If Yes, please advise the most recent date

Patient contact details

Mobile Phone

Home Phone

Do you have a current email address? *

YesNo

Work Phone

Address *

City / Suburb *

State *

Postcode *

Consultation fees

Please see our website FAQ and Links tab for details of consultation fees for rooms and hospital visits. In the event where your overdue account is referred to a collection agency and/or law firm, you will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs. Please note that a Medicare subsidy is payable only with a current written referral

Medicare number (top line of your card, plus the reference number to the left of your name)

Medicare card first 4 numbers

Medicare card second group of numbers (5 only)

Medicare card final number on top line (1 number only)

Expiry MM/YYYY

Private Health Insurance

Do you have private health insurance? Please note, Health Funds do not subsidise rooms appointments for physicians *

YesNo

Your health insurance company (please choose from drop down list): *

If the company is not listed, please advise the name:

Health insurance company membership Number:

Pension / HCC/DVA Card or TAC/Workcover

Do you have an aged pension card, Healthcare card or a DVA card? *

YesNo

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

DVA No.

If this appointment being covered by TAC? *

YesNo

TAC claim number

Is this appointment being covered by Workcover? *

YesNo

Workcover company

Workcover claim number

Reason for referral

Why have you been referred to us? *

Pre-surgicalDeep vein thrombosis (DVT)Renal (kidney)Other (please specify)

Other reason for referral

Referring doctor to us

Referring Doctor’s Name *

Referring Doctor Address *

Are you attaching your referral to us (note: a Medicare rebate is only payable to patients with a current written referral)? *

YesNo

Please upload your referral here, if attaching

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Have you had any blood tests/ultrasound/other tests requested by your referring doctor? *

YesNo

If yes, when did you have your tests done (note: tests should be done at least a week ahead of your appointment with us)?

Which pathology company/other medical test company (eg Melbourne Pathology, Dorevitch)?

If your referring doctor is a surgeon, have they suggested a surgery date?

YesNo

If yes, the planned surgery date is:

If your surgeon has suggested rehabilitation after your surgery, have they suggested which facility?

Your GP (family /regular doctor)

Is your GP the doctor who is referring you to Dr Flanagan? *

YesNo

If no, please advise your GP's Name (and/or clinic name if applicable)

Your GP's/clinic's address

Do you see a Cardiologist? *

YesNo

Cardiologist name

Cardiologist address

Other doctor? *

YesNo

Other doctor type (eg Rheumatologist)

Other doctor name

Other doctor address

If you see more than one other doctor, please add their information here

Health information

Do you have diabetes? *

YesNo

If Yes, Type 1 or Type 2?

Type 1Type 2

If yes, how is your diabetes managed?

diettabletsinsulinn/a

Do you have high/low blood pressure? *

YesNo

If yes, is your blood pressure controlled by medication?

YesNon/a

Nutrition information

Do you require a special diet? *

YesNo

Do you have speech or swallowing difficulties? *

YesNo

Any appetite problem causing weight loss? *

YesNo

Have you lost over 5kg without trying? *

YesNo

Lifestyle - do you:

Drink alcohol? *

YesNo

Smoke? *

YesNo

Have you ever smoked? *

YesNo

Use recreational drugs? *

YesNo

If yes to any of these lifestyle questions, please specify the quantity and frequency:

Allergies

I have known allergies *

YesNo

My known allergies are: (please specify)

Health history - please tick if "Yes", and provide further info for all answered as "Yes"

If you ticked "yes" to COVID-19, please advise the most recent date:

Other/further information/any other health issues you have:

I have attached a list of my medical history/other relevant information *

YesNo

Please click here to upload any files (eg Medical History)

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Medications

Are you taking any medications, including vitamins, supplements, natural medications, herbs, herbal medications, herbal tea/other drinks, fish oil, krill oil, ginseng, ginko or garlic supplements?? *

YesNo

Medication 1 - name, strength and frequency

Medication 2 - name, strength and frequency

Medication 3 - name, strength and frequency

Medication 4 - name, strength and frequency

Medication 5 - name, strength and frequency

Medication 6 - name, strength and frequency

Medication 7 - name, strength and frequency

Medication 8 - name, strength and frequency

Medication 9- name, strength and frequency

Medication 10- name, strength and frequency

Medication 11- name, strength and frequency

Medication 12- name, strength and frequency

Are you attaching a list of your medications? *

YesNo

If you are attaching a list of your medications, please upload here

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Do you administer your own medications? *

YesNo

If planning surgery, have you been instructed to stop any medications prior to your admission? If so, please provide details:

Are you taking blood thinning medications (eg aspirin, Plavix, Clopidogrel, Cartia, warfarin, Pradaxa, Xarelto, Eliquis)? *

YesNo

If yes, please provide details

Final questions

I understand that any tests ordered by my referring doctor should be done a week ahead *

I understand that I may bring only one support person to rooms appointments, who needs to be aged 16 or over *

If suffering any COVID-19 symptoms/otherwise unwell on the day I will ring to reschedule *

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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