Please note: items marked * indicate mandatory fields. 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 Year19251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Contact details Address * Suburb * State * -Select-ACTNSWNTQLDSATASVICWA 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 Year20252026202720282029203020312032203320342035 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 Next of kin Name Partner Phone Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432 Next of kin Phone Relationship to next of kin Account Details Are you the person responsible for account? * Yes No Account First name * Account Last name * Patient Details Is the patient under 14 years of age? * Yes No Parent or Guardian First name * Parent or Guardian Last name * Parent or Guardian Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20232024202520262027 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 Are you alergic to latex? -Select-YesNo (i.e. rubber gloves) Do you have a history of heart problems -Select-YesNo Specialist detailsIf there are any other specialists that require clinical information, please fill the information below. Specialist Name Speciality Specialist Medical Practice Name Specialist Phone + More Consent to release medical information I give my consent to Dr Daniel Timperley, 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 Dr Daniel Timperley, 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. Website Continue
