Victorian Dermatology &Surgery
Dr. Tim Rutherford (MBBS, FACD)
Dr. Adam Sheridan (MBBS, FACD)
Dr. Edward Upjohn (MBBS, FACD)
Lev 1/253 Wattletree RoadPhone: (03) 9509 1417
Malvern VIC 3144 Fax: (03) 8678 3214
CONFIDENTIAL PATIENT REGISTRATION
Personal Details: Dr / Mr. / Mrs. / Ms / Mast / Miss / Other______(Please circle)
Surname:______Given Names:______
Address:______
______Postcode:______
Date of Birth:______
Phone: Home______Work______Mobile______
Email:______
Occupation:______
Next of Kin:______Relationship:______
Contact Phone No:______
Name of your GP (if different to referring doctor):______
Address:______
Phone:______
Medicare Number:______Ref No*:______Expiry:______
(*The Ref No is located beside your name on the left hand side of your Medicare Card)
Aged or Disability Pension No: ______Exp:______
Health Care Card No: ______Exp:______
Veterans Affairs VX No:______Card Colour:______
Private Health Insurance
Fund Name:______Membership No:______
Continued over….
MEDICAL HISTORY
Please complete the following important information
Current & Prior Illnesses:
______
Previous Operations:
______
Current Medications:
______
Allergies
______
Please tick the boxes relating to the following conditions
YesNo
HEART ATTACKor ANGINA within the last 6 months□□
STROKE within the last 6 months□□
SEVERE RESPIRATORY DISEASE such as severe asthma,□□
Chronic bronchitis, emphysema or sleep apnoea.
BLEEDING DISORDER such as Hemophilia,□□
Von Willebrands disease or Platelet disorder.
DIABETES requiring Insulin or tablets□□
PREGNANCY□□
WARFARIN or ANTICOAGULANTS are being taken□□
DISEASE of/or ARTIFICIAL HEART VALVES□□
CARDIAC PACEMAKER present□□
RECENT JOINT REPLACEMENT in the last 2 years□□
INFECTIOUS DISEASE such as Hepatitis B, Hepatitis C,□□
HIV, Tuberculosis or MRSA
IMPORTANT INFORMATION REGARDING PAYMENT DETAILS
All fees are due and payable at time of consultation, any procedures performed on the day are charged additional to the consultation fee but again are Medicare claimable accounts.
Unfortunately we do not bulk bill, however for your convenience we can accept::
EFTPOS, Visa, MasterCard, Bankcard & Cash
Health Records Act 2001 Collection Statement
The personal health information that you provide during your consultation and subsequent treatment will be collected for the purpose of providing you with high quality health care.
The clinic’s policy is to protect your privacy and this information will only be disclosed to other members of your treating team where necessary. It will, however, be disclosed to other organisations where required by law or, if necessary for debt recovery purposes.
I have read, understood and agree to the above and consent to my health information being collected by Victorian Dermatology & Surgery.
Signature:______Date:______
Authoristation and Consent to Photography
I,______hereby consent that photographs be taken of me by my doctor.
Victorian Dermatology & Surgery at all times respects patients rights to privacy and informed consent for procedures within the practice including photographs.
I understand and consent to my photographs being used by my doctor for medical research, teaching and/or patient education purposes.
I understand that I will not be identified by name in any such photographs, however in some circumstances the photographs may portray features that shall make my identity recognizable.
I have read, understood and agree to the above and consent to my health information being collected by Victorian Dermatology & Surgery.
Signature:______Date:______