newcastle skin - new patient formplease complete the following form and submit when finished Please choose one: Mr Mrs Ms Miss Master Name * First Name Last Name Known as * Date of Birth * If under 18 please complete guardian details below IF UNDER 18 PLEASE COMPLETE THE GUARDIAN DETAILS BELOW GUARDIAN DETAILS: First Name Last Name GUARDIAN'S Date of Birth GUARDIAN'S Medicare Card Number Medicare Reference No ( number next to name on card) Expiry Date END OF GUARDIAN DETAILS Address * Postal Address If different from above Home Phone Number Work Phone Number Mobile Phone Number * Email * Next of Kin - Name * For contact purposes Next of Kin - Contact Phone Number * Next of Kin - Relationship to Patient GP Name and Practice * Medicare Card Number * Medicare Reference No (number next to name on card) Expiry Date * Pension Card Number Expiry Date DVA - Veteran's Affairs Number Expiry Date PLEASE PRESENT ALL CARDS TO RECEPTION FOR CONFIRMATION Please complete if not on your referral, if different from your referral or if you have no referral: Past Illnesses/Operations: Family History of Melanoma Please note any previous family history of skin cancer. If not know - write ' Not known' Any Lesions of Concern Pleas note any specific spots that you are concerned about Current Medications: Allergies: Pacemaker - Do you have a pacemaker? YES NO Consent - I give my consent for Newcastle Skin to release medical information in regard to myself to my referring practitioner, other treating doctors and hospitals where I have been treated. YES NO Photography Consent - I agree that images taken by my doctor on behalf of Newcastle Skin may be placed in my electronic file for future reference. YES NO Please acknowledge the following by placing a tick in the box: I acknowledge that any additional procedures will incur an additional fee and I can discuss this with the administration staff. I acknowledge that any pathology will incur an invoice from the pathology company, unless I possess a concession card such as a Health Care Card, Pension card or Veterans card. I acknowledge that all information provided herewith is true and correct to the best of my knowledge. Today's Date * Thank you for completing our new patient details form. We will set up your Newcastle Skin patient file ready for your appointment.
