Patient Registration Form Consent Patient Information Form Last Name * Title * Select Mr Mrs Miss Ms Dr Given Names * Date of Birth * Age * Address & Post Code * Email Address * Home Phone Work Phone * Mobile Phone * Next of Kin * Relationship * Contact No. * Referring Doctor * Referral Date GP * Do you have private health insurance? * Yes No Name of Fund * Membership No. * Medicare Number * Do you have a concession/healthcare card? * Yes No Enter Card Number * Medical History * Please Select * Diabetes Blood Thinners Previous Weight Loss Surgery Pacemaker/Difib Weight Loss Injections None Weight (kg) * Height * Current Medications / Injections * Do you have allergies (to drugs or latex)? * Yes No List Allergies * Do You Smoke? * Yes No If yes, how many per day? * Do You Drink Alcohol? * Yes No If yes, how much per day/week? * Reason for Referral Past Operations Patient Consent Please review the consent form before submitting your registration. View Consent Form Signature * Clear I have read and agree to the Consent Form. Submit Form
