New patient registration form

BOOK YOU APPOINTMENT

First Name*

Last Name*

DOB*

Address

Mobile*

Medicare Number

Referring Doctor*

Type of booking*

Are you a new patient?

Yes No

Upload Referral

Residential Address *

Emergency Contact person *

Name of your usual Dr (GP) *

Consent to release medical documents

Have you had any recent admission to Hospital relating to your heart?

Have you seen a Cardiologist in the past? *

How did you hear about us? *

Have you had any recent Cardiac related tests

Have you had any recent Cardiac related Procedures

If you indicated any from the above please state: test, clinic/hospital and date

Medications List Do you take the following Medication?

Are you Allergic to anything?

Reason for taking: (e.g. Blood Pressure):

I consent to the release / access by the Rotar Heart Health staff of my medical record to / of any health service provider that requires the information for the purpose of treatment or audit of my current, past or any future conditions.

CARDIOLOGY CENTRE