Your name, address

Patient Registration Form

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 Appointments tab for fee information.
Once we have your completed form, referral and test results (if you referring doctor has ordered any tests), we will contact you for an appointment

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 *

Your Medicare, health fund info

Consultation fees

Please see our website 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-surgical assessmentDeep 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 subsidy 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?

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) and any other doctors

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 name/s and address/es here

Your health information

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:

Your allergies, other health info

Allergies, height and weight

I have known allergies *

YesNo

My known allergies are: (please specify)

What is your height (approximately)? *

What is your weight (approximately)? *

I understand that excess weight significantly increases my risk of complications with surgery *

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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Your medications incl supplements

Medications

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

YesNo

If yes, please provide details

Are you taking Ozempic, Mounjaro, Rybelsus, Wegovy, Prednisolone, insulin or methotrexate? *

YesNo

If yes to this question, please provide details

Are you taking any other doctor-prescribed medications? If you have a current list, please attach it (see below) *

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

YesNo

Please give details of your other herbal/natural/other supplement/s:

Are you attaching a list of your medications? *

YesNo

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

Browse

Have you been prescribed a CPAP machine? *

YesNo

Please advise the name and address of the doctor who prescribed your CPAP machine:

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:

Final questions

I understand that I will be contacted for an appointment once Dr Flanagan's staff have received the results of tests (if any) ordered by my referring doctor, my completed Patient Registration Form and the referral from my doctor *

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

I have read the Privacy Policy on the FAQ and Links page of Dr Flanagan's website and understand that by registering as a patient of his practice, I provide consent for Dr Flanagan and practice staff to access and use my personal information so they can provide me with the best possible healthcare. This may include information accessed from other healthcare providers, such as other doctors, hospitals, and pathology services. Dr Flanagan may refer me to other and/or new medical services, to whom he may provide my information. *

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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