Patient Registration

To save time during your first visit, please fill out your registration details below so that we can create a medical file for your surgeon to record his treatment notes.

Alternatively your form may be completed on arrival, please arrive 15 minutes early to complete your form in person.

Refer to our Privacy Policy if you have any concerns.

Personal Details

Title

First Name *

Last Name *

Date of Birth *

Address *

Suburb *

State *

Postcode *

Phone

Mobile Phone *

Work Phone

Email *

Occupation *

Account Details

Medicare Number *

Reference Number (number next to your name) *

Private Health Insurance *

Hospital Cover *

Dental Extras Cover *

Fund Name

Membership Number

Responsible for Fees (write "self" if the patient is paying the account) *

Responsible for Fees Phone Number

Medical History

Doctor *

Phone Number *

Address *

Suburb *

Postcode *

Dentist *

Phone Number *

Address *

Suburb *

Postcode *

Emergency Contact Name *

Emergency Contact Phone Number *

Do you have any of the following?

Prosthetic Joint *
Yes No

High Blood Pressure *
Yes No

Osteoporosis *
Yes No

Asthma *
Yes No

Anxiety / Depression / Psychological Disorder *
Yes No

Heart Attack / Angina *
Yes No

Prosthetic Heart Valves / Pacemaker *
Yes No

Diabetes *
Yes No

Autoimmune Disease *
Yes No

Fits or Epilepsy *
Yes No

Bleeding Problems *
Yes No

Hepatitis *
Yes No

Other

Do you have any allergies to medications or substances?

Please list any medications you are taking (include ventolin puffers and contraceptive pill)

Have you had a General Anaesthetic? *
Yes No

Any complications related to general anaesthesia?

Please list any previous operations that required admission to hospital:

Do you smoke? *
Yes No

Ladies - Are you pregnant? *
Yes No

Guardian

If the patient is under 18 years of age, a parent or guardian must sign and provide a daytime contact number.

Guardian Name

Guardian Phone Number

Make an Appointment

Refer a Patient

Epworth Freemasons
Suite 1, Ground Floor
124 Grey Street
EAST MELBOURNE 3002
(03) 9654 3799
(03) 9650 3845
info@dimitroulis.com