New Patient Information

PLEASE COMPLETE BEFORE YOUR first APPOINTMENT

This form will take 2-3 minutes to complete. Please ensure you have your Medicare card with you. You can alternatively download a PDF copy of the form and email to us once completed.

Fields marked with * are compulsory.

Title

Title, Pronoun (he/she/they)

First Name

(as per Medicare card)

Surname

As per Medicare Card

Preferred Name

Address

Date of Birth

Email Address

We are able to email some ESC medical documentation to you. Please select your preference.

I am willing to receive ESC medical documentation via EmailI

I do not wish to receive ESC medical documentation via email and would prefer this to be posted

Phone (home)

Home

Phone (work)

Phone (mobile)

Medicare No

Medicare IRN (Individual Reference No)

Expiry Date

Veterans Affair No

Expiry Date

Pension No:

Date of Expiry

Please note a copy of your pension card will need to be sighted by ESC

Referring Doctor Name & Address

Name & Address of Any Other Doctors

Current Medications

Allergies

Emergency Contact Name

Emergency Contact Phone

Acknowledgement

I understand that Professor Jeffrey Zajac/Professor Joseph Proietto are consulting in private capacity and independently of the University of Melbourne.

Date

Please note that this is a Private Specialist Centre and therefore fees are charged for your consultation with our Endocrinologists. Please call us prior to your appointment if you wish to be advised of the fee that will be charged for your consultation. In individual circumstances reduced fees may be applied.

New Patient Information

PLEASE COMPLETE BEFORE YOUR first APPOINTMENT

© ENDOCRINE SPECIALIST CENTRE

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Ivanhoe

VERMONT SOUTH

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GPs & specialists

Health Services