New Patient Registration

If you are a new patient at Brisbane Breast and Endocrine Surgeons the following form can be completed. This will save time on the day of your appointment. If you are unable to complete the form online it can be completed on the day, please arrive 10 minutes prior to your appointment.  

New Patient Registration Form

Please note: items marked * indicate mandatory fields.

Personal details

Title * - Select -MrMrsMissMsDr

First Name *

Last Name *

Preferred name

Occupation

Date of Birth *

Day Day12345678910111213141516171819202122232425262728293031

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Year Year19191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019

Contact details

Address *

Suburb *

State * - Select -ACTNSWVICSAQLDNTWATAS

Postcode *

Email *

Home Phone

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

Work Phone

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

Mobile Phone

Please enter your full mobile number. No spaces please. 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)

Day Day12345678910111213141516171819202122232425262728293031

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Year Year20192020202120222023202420252026202720282029

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 - None -GoldWhiteOrange

Do you require DVA transport booked for you?

Yes

No

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

Existing, diagnosed conditions

Previous operations

Current Medications

Including over the counter medications

Current Vitamins or Dietary Supplements

Allergic reactions (Drugs or other causes)

Drugs or other causes

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

+ More

Consent to release medical information

I give my consent to Brisbane Breast and Endocrine Surgeons, 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 Brisbane Breast and Endocrine Surgeons, 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.

Consent *

Yes, I consent to the above.

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