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Book an Appointment

About Us
Clinic Times & Locations
Common Allergy Conditions
Contact Us
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Patient Registration Form
Refer a Patient

New Patient Registration Form

To book an appointment, it is necessary to provide personal information so that a file can be created. It is also necessary to list the name of medical practitioners to whom a report may be supplied.

If you would like to download the form and fill it out instead, please click here:

Download New Patient Registration Form

Please upload the completed form here.

Please fill and submit this form:

Personal Details

Title

First Name *

Middle Name/s

Last name/s *

Known as

Date of Birth *DD / MM / YYYY

Gender *

Occupation *

Contact Details

Residential Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Postal Address (if different from Residential Address)

Home Phone *

Work Phone *

Mobile Phone *

Email Address *

Medicare & DVA

Medicare Card Number *

Medicare Position Number *

DVA Number (Gold Number Only)0 / 9

Parent 1 Name (For Minors (under 18 only))

Parent 1 Date of Birth

Parent 1 Medicare Card Number

Parent 1 Medicare Position Number

Parent 2 Name (For Minors (under 18 only))

Parent 2 Date of Birth

Parent 2 Medicare Card Number

Parent 2 Medicare Position Number

Referring Doctor Details

Name *

Practice Name *

Address *

Phone Number *

Family Doctor Details

Same as referring doctor

Name *

Practice Name *

Address *

Phone Number *

Next of Kin / Emergency Contact

Name *

Relationship *

Phone Number *

Clinical Details - Chief Complaint/ Reason of Visit

1. Please TICK ONE of the following clinical conditions which most likely represents your allergy condition. *Hay FeverEczemaHivesAsthmaInsect Sting - Bee, Wasp, Jumper AntFood Allergy - Specific - Egg, Milk, NutsFood Allergy - Unknown/MultipleAnaphylaxis - Known CaseAnaphylaxis - Unknown CaseNone of the listed

If none of the listed, please detail

2. Please detail any other pre-exisiting allergy condition

3. Additional allergy conditions of concern

4. Please upload and give a description of any relevant documents (RAST, Lung function, CT sinus and rash photographs etc.)

Upload file/s

No file chosen

Privacy

Allergy Medical Clinic collects information from you for the primary purpose of providing medical care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose and treat you.

We will use the information you provide in the following ways:

1. Administrative purposes in running the medical practice

2. Billing purposes

3. Compliance with Medicare

4. Disclose to other doctors and other doctors as permitted

Payment

Payment is required by credit card on attendance for the appointment.

Patient Declaration

I have read and agree to the privacy and payment arrangement.I confirm that the medical information that I have provided is accurate.I will notify Allergy Medical Clinic of any change to my allergy condition.

Signature of patient or guardian *

Start signing your signature here

Name Print *

Date *

Clinic Locations

Richmond
Toorak
Wantirna
Berwick
Werribee

Get in Touch

03 9429 5377
03 9429 5452
www.allergyclinic.com.au
patient-enquiry@allergyclinic.com.au

Preferred Providers

Pathology:
Melbourne Pathology

Imaging:
Lumus Imagining

Lung Function:
Monash Medical Centre
Alfred Hospital
Austin Hospital
Royal Melbourne Hospital

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