Patient Registration – Wodonga Specialist Obstetricians & Gynaecologists

Patient Details
Title *	Title Miss Mrs Ms
First Name *
Surname *
Middle Name
Preferred Name *
Previous Surname	(e.g. Maiden Name)
Date Of Birth *	DD/MM/YYYY (Examples: 20/01/2000)
Address
Street *
Suburb/ Town *
State *
Postcode *
Phone & Email
Home Phone
Work Phone
Mobile Phone *
Email Address *
Confirm Email Address *
Usual GP
Name *
Clinic *
Location *
Medicare Details
Medicare No *
Prefix No *	(The number next to your name)
Expiry Date *	MM/YYYY
Private Health Fund
Do You Have Hospital Cover? *	Do You Have Hospital Cover? Yes No
Name of Fund
Membership No
Have You Served Any Waiting Periods?	Have You Served Any Waiting Periods? Yes No
If Not, Please Specify
Health Care / Pension Card / DVA Details
Expiry Date
Health Care/ Pension Card No
DVA Card No
DVA Card Type	DVA Card Type White Gold
Indigenous Status
Are You of Aboriginal Origin *	Are You of Aboriginal Origin Yes No
Are You of Torres Strait Islander Origin *	Are You of Torres Strait Islander Origin Yes No
Occupation
Your Occupation
Next of Kin / Emergency Contact (This is the person we will contact if we are unable to contact you)
Relationship *
Name *
Mobile Phone *
Interpreter Required
Do You Need an Interpreter?	Do You Need an Interpreter? Yes No
If Yes, What Language?
Consent
Privacy Consent *	I have read and agree to the Privacy Information & Consent Form
Private Patients Only	I have read and agree to the IMC Patient Claim Consent & Declaration
I give permission for appointment reminders and results to be sent via SMS
Signature *
Spam Check
Captcha *	9 + 2 = ?

PLEASE NOTE

Public Patients – should you require surgery at Albury Wodonga Regional Health Service (Wodonga Hospital) as a Medicare patient, then the surgery will probably be performed, at least in part, by the trainee gynaecologist under the consultant’s supervision.

Please read important information about Patient Privacy

Patient Details

Address

Phone & Email

Usual GP

Medicare Details

Private Health Fund

Health Care / Pension Card / DVA Details

Indigenous Status

Occupation

Next of Kin / Emergency Contact

Interpreter Required

Consent

Spam Check