New Patient Registration Form | Dr Steven Hatzikostas

New Patient Registration

NOTE: * indicates required fields.

Personal details

Title*
First Name*
Last Name*
Preferred name
Date of Birth*
Contact details
Address*
Suburb*
State*
Postcode*
Email*
Mobile Phone*
Please enter your full mobile number. No spaces please. eg. 0412345678
Home Phone
Please enter phone number with area code included. No spaces please. eg. 0298765432
Work Phone
Preferred Contact Method*
Memberships
Medicare number
Medicare Reference
Number next to your name
Date
Private Health Fund Name

eg. HCF, NIB, Bupa
Private Health Fund Number
Emergency contact
Partner Name
Partner Date of Birth
Next of kin name
Relationship to next of kin
Next of kin phone
Medical Information
Referring Doctor Name
Referring Doctor Phone
Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432
Occupation
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
Allergic reactions
Drugs or other causes
Specialist
If there are any other specialists that require clinical information please fill the information below.
Specialist Name
Speciality
Specialist Medical Practice Name
Specialist Phone
Untitled
Consent to release medical information
I give my consent to Dr Steven Hatzikostas, 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 to Dr Steven Hatzikostas, 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.
*
- Yes, I consent to the above.
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New Patient Registration

Contact details

Memberships

Emergency contact

Medical Information

Specialist

Consent to release medical information

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