Patient Registration

Patient Details

First Name *

Last Name *

DOB *

Gender (for medical care) *

Phone Number *

Email Address

Street address *

City *

State *

Postcode *

Next of Kin Name *

Relationship to Next of Kin *

Next of Kin Phone Number *

Are you eligible to claim Medicare? *

YesNo

Are you a DVA Card Holder? *

YesNo

DVA Card Type *

GoldWhiteOrange

Medicare/DVA Number *Patient medicare number

Reference *

Expiry *

Do you have a concession card *

YesNo

Type of Concession Card *

Concession Card Number *

Do you have private health insurance? *

YesNo

Health Insurer *

Membership Number *

Name of your regular Doctor/GP *

Address of regular Doctor/GP *

I consent to being contacted by The Iron Infusion Clinic via SMS, email and/or phone regarding my booking and related services.

My contact details will be used solely for this purpose and will not be shared with third parties.

*

Please verify you are a human user *