New Patient Registration

Please note: items marked * indicate mandatory fields.

Personal details

Title

Firstname

Surname

Occupation

Preferred Name

Date of Birth

Contact details

Address

Suburb

State

Postcode

Home Phone

Please enter phone number with area code included. No spaces please. eg. 0298765432

Mobile Phone

Preferred Contact Method

Memberships

Medicare Number

10 Digits

Medicare IRN

1 digit next to cardholder's name

Medicare Expiry

Private Health Fund Name

eg. HCF, NIB, Bupa

Are you a member of the Department of Veterans Affairs (DVA)?

Yes

Emergency contact

Partner Name

Partner Phone

Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432

Next of kin Name

Next of kin Phone

Relationship to next of kin

Medical Information

Referring Doctor Name

Referring Doctor Phone

Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432

Medical History *

Yes – I do have relevant medical history, detailed below

No – I do not have relevant medical history

If there are any other specialists that require clinical information, please fill the information below.

Specialist details

Specialist Name

Speciality

Specialist Medical Practice Name

Specialist Phone

Consent to release medical information I give my consent to Obesity Clinic Queensland, 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 Obesity Clinic Queensland, or their agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. For more information view our Patient Information Privacy Statement on this website.

Yes, I consent to the above.

I agree to have my details saved

Email address