New Patient Registration

Personal details

Title * First Name * Last Name * Preferred Name Occupation Date of Birth *

Contact Details

Address * Suburb * State * 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 *

Memberships

Medicare Number

10 digits

Medicare IRN

1 digit next to cardholder's name

Medicare Expiry (MM/YY)

Private Health Fund Name

eg. HCF,NIB,Bupa

Private Health Fund Membership Number Are you a member of the Department of Veterans Affairs (DVA)?* YesNo

Emergency Contact

Partner Name Partner Phone

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

Next of kin Name Next of kin Phone

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

Relationship to next of kin

Medical Information

Referring Doctor Name Referring Doctor Phone

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

Medical History * Yes – I do have relevant medical history, detailed belowNo – I do not have relevant medical history

Specialist Name Speciality Specialist Medical Practice Name Specialist Phone

Consent to release medical information

I give my consent to Dr Archie Lamb, 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 Archie Lamb, 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.

Yes, I consent to the above. *