\ New Patient Registration New Patient Registration Title*Title<span class="req">*</span>ProfDrMrMrsMsMissFirst Name*Surname*Street Address*Street Address Line 2Suburb*State*Postcode*Birthdate*Age*Sex*MaleFemaleWeight (kg)Height (cm)OccupationHand Orientation*Left HandedRight HandedEmail Address*Home Phone Number*Mobile Number*Work Phone Number*Next of KinName of Next of Kin*Next of Kin Relationship*Next of Kin Telephone Number*Referring DoctorReferring Doctor*Street Address*Suburb*State*Postcode*Telephone Number*Fax Number*General PractitionerGP*Street Address*Suburb*State*Postcode*Telephone Number*Fax Number*Insurance InformationMedicare Number*Medicare Reference Number*Expiry Date*Private Insurance FundMembership NumberLevel of CoverVeteran AffairsGoldBlueWhiteVX NumberAged Pension NumberAged Pension Expiry DateWorkcover Insurance CompanyClaim NumberContact PersonTelephone NumberFax NumberEmployerStreet AddressSuburbStatePostcodeEmployer's Telephone NumberEmployer's Fax NumberMAIB/TACClaim NumberContact PersonTelephone NumberFax NumberDesired LocationWhich region do you like prefer?*Which region do you like prefer?<span class='req'>*</span>QueenslandTasmaniaVictoriaNew South WalesWhich location would you like to visit?*Which location would you like to visit?<span class='req'>*</span>MackaySouthportTugunWhich location would you like to visit?*Which location would you like to visit?<span class='req'>*</span>DevonportHobartLauncestonWhich location would you like to visit?*Which location would you like to visit?<span class='req'>*</span>BendigoBox HillBundooraCranbourneDandenongDoncasterEast EppingEssendonGeelongKewKnoxMilduraPakenhamVermontWarragulWerribeeWhich location would you like to visit?*Which location would you like to visit?<span class='req'>*</span>AlburyMedical InformationPlease Tick If You Take Any Of The Following Medications*AspirinWarfarinPlavixClopidogril or other antiplatelet or blood thinning medicationsNone of the aboveCurrent Medications You Are TakingInclude medication name, dosage, and frequency. One medication per line, please. Example: Aspirin, 4mg, 3 times a day Tylenol, 6mg, twice dailyPlease Indicate If You Take The Following Herbal Supplements / Remedies*ChamomileFeverfewSt. John's WortGinsengGarlicGingerGinko BilobaNone Of The AboveDo You Have Any Allergies?*YesNoPlease Indicate If You Suffer / Have Had Any Of The Following Medical Conditions*High Blood PressureOpen Heart SurgeryChronic InfectionHeart AttackCardiac StentMigrainesAnginaStroke / TIADVT / PEAsthmaDiabetesNotifiable DiseaseNone Of The AbovePlease List Any Previous SurgeryInclude surgery date, surgery, surgeon, and complications. One surgery per line, please. Example: 10/01/2002 Appendectomy, Dr. Jones, minor bleeding 14/07/2011 Rhinoplasty, Dr. ConnorPlease List All Other Doctors You Are SeeingInclude doctor name, location, phone number, and specialty. One doctor per line, please. Example: Dr. Smith, Kew, (08) 8377 8545, NeurologistMRI Safety Check*Done Any Welding, Grinding or Sheet Metal WorkA Cardiac Pacemaker or DefibrillatorA Bionic Ear / Cochlear ImplantA Brain / Cerebral Aneurysm ClipAny Metallic Surgical Implant or Foreign BodiesA Spinal Cord Or Deep Brain Stimulation DevicePeripheral Nerve Stimulation DeviceHistory of Metal Fragments In The Eye, Head or BodyShrapnel or Gunshot WoundsShunt ( Spinal or Ventricular )ClaustrophobiaNone Of The AbovePlease Indicate If You HaveReferral Document(s)Payment Checkbox** I understand that payment of my account is my responsibility and that my health fund / medicare / insurer may not cover the total amount invoiced. I am responsible for any further costs that might be incurred resulting from my not paying my account, in full, by the due date.Payment Schedule Checkbox** I have read and acknowledge the fee payment schedule.Share Details Checkbox** I understand that details of my medical condition(s) may be revealed to other medical and paramedical practitioners, for the purpose of optimising my treatment.* Some Precision, Brain Spine & Pain Specialists may be shareholders in Radiology Companies, Vermont Private Hospital, Surgical Equipment Manufacturers, Precision, Brain Spine & Pain Centre, and/or Precision Ascend. In addition, some Precision, Brain Spine & Pain Specialists may have consultancy agreements with companies that manufacture or distribute surgical implants or other medical devices. If you require further information, this can be obtained from the relevant specialist or by contacting Precision, Brain Spine & Pain Centre.* As part of your diagnostic workup and treatment you may be referred to other practitioners at Precision, Brain Spine & Pain Centre. If you would prefer to see a different practitioner who is not affiliated with Precision, please ask your GP to arrange this.Research CheckboxI give permission for information relating to my medical condition(s) and treatment to be used for research and audit purposes. When this is done, I understand that my identity will be protected.SendThis field should be left blank
