Securely submit your registration information direct to Vein Artery Specialist. Today's Date Patient Name* Choose an optionMrMrsMsMst Gender* Choose an optionMaleFemalenon-binaryprefer not to say Date of Birth* Phone (if a landline, include area code)* Other phone Email Patient Address* StateNew South WalesQueenslandSouth AustraliaTasmaniaVictoriaWestern AustraliaAustralian Capital TerritoryNorthern Territory Medicare Number ( include reference number )* Private Insurance* YesNo Private Insurance Name Membership Number Next Next of Kin* Choose an optionMrMrsMs Relationship* Next of Kin phone ( Include area code ) Next of Kin mobile Email Additional Next of kin Choose an optionMrMrsMs Phone - Mobile or landline (landline with area code) BackNext Referring Doctor* Choose an optionDrMrMsProf Speciality Choose an optionGeneral PractitionerSpecialistOther Phone Address Other Treating Doctors Other Treating Doctors (It is important to keep all of your treating doctors informed of your medical report. Please provide their names and contact details.) send correspondence? Do you consent to have your health information disclosed to “My Health Record”?* YesNo Upload referral letter Consent* I consent to the collection, storage, use and disclosure of personal health information I acknowledge that my consultation will incur a fee as outlined in this fee schedule, to be paid at the time of consultation. I acknowledge Back
