If you are a new patient of our clinic please complete the information below. If you prefer a PDF you can print, then scan or photograph with your phone and email to reception@drkatiebethwebster.com

PDF Registration Form

Title/Preferred Pronouns

Name *

First Name

Last Name

Date of Birth *

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile OR Home Phone *

Email Address *

Next of Kin

Insurance Information

Medicare Number

Health Insurance Company

Member Number

Type of cover

We can admit you to a private hospital only if you have Hospital Cover

Hospital only

Hospital and Extras

Extras only

Don't know

Level of Cover

Check with your insurance company if unknown

Gold

Sliver

Bronze

Don't know

DVA Number

Workcover Claim or TAC Claim

Referring Doctor Information

Referring Doctor/Specialist *

Is this your usual GP?

Yes

If no, please provide your regular GP's details

Other specialists interested in your care

Medical Questionnaire

The questionnaire helps us decide how to best look after you. The information will form part of the medical records and is STRICTLY CONFIDENTIAL. If there is anything you are unsure about, please ask.

What is the main symptom or problem you need help with?

List your current medications, including over the counter and non-prescribed tablets:

List any active or previous medical conditions:

Have you every been admitted to hospital?

Yes

If so, what for?

Have you every had any previous surgery?

Do you take Warfarin, Isocover, Plavix, Pradaxa, Eliquis or Xarelto or other blood thinner?

Do you have any allergies?

Do you live alone?

This is important after discharge from hospital

Yes

If not, who is at home with you?

Do you have children?

Do you smoke?

Yes

Are you an ex-smoker?

Yes

Do you drink more than two alcoholic drinks per day?

Yes

Are there any illnesses that run in the family?

Yes

If yes, please specify

Have you had a skin biopsy?

This helps us speed up and simplify your care

Thank you! We will be in touch shortly