Patient Registration Form

Details

MrMrsMissMsDr

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender

MaleFemaleOther

Contact Information

Home Phone

Mobile Phone *

Work Phone

Email *

Address *

Postcode *

Emergency Contact Details

Name *

Address

Postcode

Mobile Phone *

Next of Kin Contact Details

Is the next of Kin same as your emergency?

YesNo

Next of kin - Relationship

ParentSpouse/ PartnerSiblingChildrenFriendOther

Name

Phone Number

Referring Doctor

Referring Doctor’s Name *

Clinic *

Family Doctor/ Regular General Practitioner Name (if different to referring doctor)

Clinic

Medicare

Do you use a different name in your medicare card?

YesNo

If you use Alias please write the Alias name & surname

Medicare First Name

Medicare Surname

Medicare Card No.Note: 10 digit number

Card Reference Number Note: Digit next to name

Expiry/ Valid ToExample: 01/2028

Medicare Address (if different to your residential address)

Private Health Insurance

Do you have private Medical insurance

YesNo

Provider

Membership No.

Expiry

Pension/ HCC/ DVA Card

Do you have an aged pension card, healthcare card or a DVA card

YesNo

Card Type

HCCPension

Card No.

Expiry

DVA Card Type

GoldWhiteLilacOrangeBlue

DVA No.

Signature

I confirm that the above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature *

Draw signature|Type signatureClear

Today's Date *

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This form will be submitted via email to Thoracic and Sleep Group Queensland. A copy will also be sent to the email address provided above.