Balwyn Dermatology - Healthy Skin, Confident You!
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Home
About Us
Patient Information
Services
Our Doctor
Contacts
GP Referral Form
Patient Registration Form
Home
About Us
Patient Information
Services
Our Doctor
Contacts
GP Referral Form
Patient Registration Form
Home
About Us
Patient Information
Services
Our Doctor
Contacts
GP Referral Form
Patient Registration Form
Patient Registration Form
Home
Patient Registration Form
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Your Personal Information
TITLE
*
Mr
Mrs
Ms
Dr
Other
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Full Name
First Name
*
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Last Name
*
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Date Of Birth
*
DD-MM-YYYY
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Gender
*
Patient’s Gender
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Address
*
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Suburb
*
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Postcode
*
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Contact Number
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Email Address
*
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Occupation
*
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Next of Kin
*
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Relationship
*
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Contact Number
*
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Person Responsible for the Account
Are you the person responsible for this account?
*
YES
NO
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Referring Doctor Details
Doctors Name
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Practice
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Medicare Details
Medicare Number
*
1234 56789 1
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Reference No
*
Next to Patient’s Name
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EXPIRY
*
MM/YYYY
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Concession/Pension Card No.
IF APPLICABLE
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Private Insurance Details
Private Insurance
YES
NO
FUND
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Membership No.
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Department of Veteran’s Affairs
DVA Number
QSM12345
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Colour of DVA Card
WHITE/ORANGE/GOLD
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DVA Expiry Date
MM/YYYY
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Medical Photography
Name
*
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Medical Record- the images will become part of your medical information that is collected for your treatment and care. This information is handled in accordance with the Health Records Act 2001.
Research- images may be used for example in journals, textbooks, publications or on the internet which can be viewed by other health professionals, medical researchers or the general public.
Education and Training- the images may be used in presentations for education nights, conferences or for other patients’ benefit when considering the same procedure.
Website and social media- images may be used in Balwyn Dermatology website and social media platforms.
Health Details
Height (CM)
*
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Weight (KG)
*
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Cigarettes/Day
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Are you allergic to any medications?
YES
NO
If yes, please state:
Are you allergic to any dressings?
YES
NO
If yes, please state:
Have you ever had any excess bleeding?
YES
NO
If yes, please state:
Are you pregnant or breastfeeding?
YES
NO
Do you have a history of the following?
Please tick if applicable.
Asthma
Heart trouble
Hepatitis
Blood clots
Cold sores/Herpes
Diabetes
Metal implant
High blood pressure
HIV
Rheumatic fever
Stroke/TIA
Pacemaker/defibrillator
How did you hear about us?
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Consent to Collect Health Information and Online Medicare & Private Health Claim for PROCEDURES ONLY
By clicking the button below, I hereby authorise Balwyn Dermatology Clinic to collect my Health Information. I understand my health information is collected for the purpose of care and may be disclosed to health departments, legal entities or other related organisations and that I have the right to gain access to this information. I also authorise
Balwyn Dermatology
Clinic to claim rebates directly from Medicare and my Private Health Fund for any agreed procedure. I understand that I will be responsible for out of pocket fees associated with any procedure and these fees are net of any rebates payable by Medicare or Health Funds.
I agree to the terms and conditions.
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Need a skin cancer check? Call us today to book your appointment.
03 8383 3750
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