Patient Admission Information Please complete the form below. Alternatively, you can download a PDF version here. PATIENT DETAILS...TitleMrMrsMissMsDrSexMaleFemaleMarital StatusMarried / DefactoSingleWidowedSeparatedDivorcedSurnameGiven NamesResidential Address Street Address Post Code Postal Address Street Address Post Code Email Address Phone: HomeWorkMobileI consent to receive SMS reminders for my upcoming appointmentsYesNoDate of BirthCountry of BirthAre you of Aboriginal or Torres Strait Islander Origin?YesNoOccupationNEXT of KIN...TitleMrMrsMissMsDrRelationshipNameAddressPhone: HomeWorkMobileName of REFERRING DOCTOR...Name of referring doctorName of GENERAL PRACTITIONER (GP)...Name of GPDo you have an ENDURING POWER of ATTORNEY?...You would use an Enduring Power of Attorney to appoint someone to make financial and / or personal decisions on your behalf if you became unable to make your own decisions.NoYesIf yes, ...please consider providing a copy for our recordDo you have an ADVANCED HEALTH DIRECTIVE?...An Advance Health Directive is a document that states your wishes or directions regarding your future health care for various medical conditions. It comes into effect ONLY if you are unable to make your own decisions.NoYesIf yes, ...please consider providing a copy for our recordENTITLEMENTS / HEALTH COVER DETAILS...MEDICARE NUMBERNumber NEXT to your name on the Medicare card EXPIRY DATECONCESSION CARD NUMBEREXPIRY DATEPHARMACEUTICAL SAFETY NET NUMBERYEAR OF ISSUEDVA NUMBER(Department of Veterans’ Affairs)Color of CardGoldWhiteOrangeDo you have PRIVATE HOSPITAL INSURANCE?YesNoIf yes, please complete the followingNAME OF FUNDMEMBERSHIP NUMBERCOMPLETED BY...Thank-you for your time. When you have your consultation, please let me know if you have any questions about this form.Name First Last SignatureDate