Please note: items marked * indicate mandatory fields. Personal Details Title * - Select -MrMrsMissMsDr First Name * Last Name * Preferred name Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Contact Details Address line 1 * Address line 2 Town/Suburb * State * ACTNSWVicSAQldNTWATas Postcode * Email * Home Phone Please enter your area code and phone number Work Phone Please enter your area code and phone number Mobile Phone Preferred Contact Method * - Select -EmailHome PhoneWork PhoneMobile Memberships Medicare Number 10 Digits Medicare IRN 1 digit next to cardholder's name Medicare Expiry Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202120222023202420252026 Valid To 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 DVA Card Level - None -GoldWhiteOrange Medical information Referring Doctor Name Referring Doctor Phone Medical History * Yes – I do have relevant medical history, detailed below No – I do not have relevant medical history Are you a diabetic? Yes No If you a diabetic, are you also insulin dependent? Yes No Existing, diagnosed conditions Previous operations Current Medications Including over the counter medications Current Vitamins or Dietary Supplements Allergies If there are any other specialists that require clinical information please fill the information below. Specialist details Specialist Name Specialty Specialist Medical Practice Name Specialist Phone + More Consent to release medical information I give my consent to Dr Shane Prodger, or his 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 Dr Shane Prodger, or his 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. Consent * Yes, I consent to the above. Continue
