Please note: items marked * indicate mandatory fields. Personal details Title - None -MrMrsMissMsDrProfOther Preferred Title First name Last name Preferred name Date of Birth Contact details Address Suburb State - Select -ACTNSWVICSAQLDNTWATAS Postcode Email Work Phone Please enter your mobile number, with no spaces: eg. 0412345678 Mobile Phone Please enter your mobile number, with no spaces: eg. 0412345678 Home Phone Please enter your mobile number, with no spaces: eg. 0412345678 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) 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 - Select -GoldWhiteOrange Do you require DVA transport booked for you? Yes No Emergency contact Next of kin Name Next of kin Phone Please enter your mobile number, with no spaces: eg. 0412345678 Relationship to next of kin Medical Information Referring Doctor Name Referring Doctor Phone Please enter your mobile number, with no spaces: eg. 0412345678 Medical History Yes – I do have relevant medical history, detailed below No – I do not have relevant medical history Existing, diagnosed conditions Previous operations Current Medications Current Vitamins or Dietary Supplements Allergic reactions Consent to release medical information This is compliant with the Privacy Act 1988 for both Australian and State or Territory Privacy Laws (as applicable). Yes, I consent to the above I give my consent to Melbourne Bladder Clinic, 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 Melbourne Bladder Clinic, or their agents and advisors, as may be requested. This is in line with the Privacy Act 1988 (Cth) (‘the Privacy Act’) updated 2018. For more information view our Patient Privacy page on this website. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
