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NEW PATIENT FORM

We look forward to welcoming you to our centre for your health needs.
For your convenience, please fill up the following form which will allow us to be prepared for your appointment.

Patient Information
Name*
Title First Middle Last Preferred Name
Date of Birth*
Date Format: MM slash DD slash YYYY
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City State Post Code Country
Home Phone
Work Phone
Mobile Phone
Email
Account Details
Medicare Card Number
Reference Number (place on card)
Expiry Date
Please list date as MM/YYYY
Pension / HCC Number
Expiry Date
Please list date as MM/YYYY
DVA Number
DVA Card Colour
Do you have private health insurance?
- Yes
- No
What is the fund name?
What is the fund number?
Have you joined/changed your health insurance in the last 12 months?
- Yes
- No
CARDIAC EXCLUSIONS?
- Yes
- No
* It is your responsibility to consult with your private insurer if you are not sure of your level of cover **Quote cardiac item numbers: 38306 38246
Emergency Contact Information
NEXT OF KIN (NOK) DETAILS (e.g. relation or family member) and emergency contact details.
Name of NOK?*
Relationship to you?*
NOK address?
Street Address Address Line 2 City State Post Code Country
Email
NOK Phone Number
NOK Mobile Phone Number
Name of Emergency Contact?*
Relationship to you?*
Emergency Contact Phone Number
Emergency Contact Mobile Phone Number
Referring Doctor Information
What is the name of your referring doctor?
What is the name of your General Practioner?
Medical Consent Release
Consent
I give consent for Peninsula Heart Centre to obtain any relevant test results, medical records and correspondence relating to my medical history.
Consent
I give consent for my results and correspondence to be sent to my referring Dr and other medical professionals involved in my care.
Consent
I am aware that at the conclusion of all consultations there will be a request for full payment of the account.
Name
Prefix First Last
Signature
Date
Date Format: MM slash DD slash YYYY
Show us that you are human to see the submit button – we specialise in?*
- Feet
- The Heart
- Teeth

TESTS

03 9789 0088

FRANKSTON

Suite11
Peninsula Private Hospital
525 McClelland Drive

MORNINGTON

Consulting Suites
Beleura Private Hospital
925 Nepean Highway

ROSEBUD

Suite 8
Peninsula Medical Suites
1533 Pt Nepean Road

03 9789 0088

FRANKSTON

Suite11, Peninsula Private Hospital
525 McClelland Drive

MORNINGTON

Consulting Suites, Beleura Private Hospital
925 Nepean Highway

ROSEBUD

Suite 8, Peninsula Medical Suites
1533 Pt Nepean Road

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