Registrations

Information

To provide a high standard of health care we need to collect personal information from our patients. This information is generally collected form the patient, but can also be collected from family members and other health care providers.

Some of the information needs to be shared with other health care providers or we may be legally bound to disclose personal information. All persons accessing your information are bound by confidentiality.

Please discuss any concerns, questions or complaints about any issues related to the privacy of your personal information with Dr Iyer.

Patient Details

Title

Dr Mr Mrs Ms Miss

First Name

Last Name

Date of Birth

Country

Select Country Afghanistan Albania Algeria Andorra Angola Antigua & Deps Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia Herzegovina Botswana Brazil Brunei Bulgaria Burkina Burundi Cambodia Cameroon Canada Cape Verde Central African Rep Chad Chile China Colombia Comoros Congo Congo {Democratic Rep} Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland {Republic} Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea North Korea South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar, {Burma} Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Federation Rwanda St Kitts & Nevis St Lucia Saint Vincent & the Grenadines Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe

Address (Optional)

Home Phone (Optional)

Work Phone (Optional)

Mobile (Optional)

Email (Optional)

Medicare Number

Reference

1 2 3 4 5 6 7 8 9

Expiry

01 02 03 04 05 06 07 08 09 10 11 12

2024 2025 2026 2027 2028 2029 2030 2031 2032 2033

Additional Details

Next of Kin

Full Name (Optional)

Phone (Optional)

Relationship (Optional)

For patients under 18

Parent Name (Optional)

Date of Birth (Optional)

Medicare Number (Optional)

Reference

1 2 3 4 5 6 7 8 9

Expiry (Optional)

01 02 03 04 05 06 07 08 09 10 11 12

2024 2025 2026 2027 2028 2029 2030 2031 2032 2033

Private Health Insurance

Do you have Private Health Insurance? Yes No

Provider (Optional)

Membership Number (Optional)

Do you have Extras in your Insurance? Yes No

Have you served 12 month waiting period? Yes No

Consession Cards

Department of Veterans Affairs

Card Number (Optional)

Expiry (Optional)

01 02 03 04 05 06 07 08 09 10 11 12

2024 2025 2026 2027 2028 2029 2030 2031 2032 2033

Health Care Card / Pension Card

Card Number (Optional)

Expiry (Optional)

01 02 03 04 05 06 07 08 09 10 11 12

2024 2025 2026 2027 2028 2029 2030 2031 2032 2033

GP Details

GP Name (Optional)

Surgery Address (Optional)

Other Treating Doctor (Optional)

Surgery Address (Optional)

Payment Details

Payment Details (Optional)

Self Payment Work Cover Health Fund

Work Cover (Optional)

Approval Number (Optional)

Employer/Company(Optional)

Other (Optional)

Consent

We ask for your consent to discuss your case with other health care providers should that be required to assist in your treatment.

Yes No - I consent for my case being discussed in multidisciplinary team meetings where needed

Yes No - I consent to photographs of clinical area or intra-operative photographs

I consent to the use of my personal health information by Dr Iyer and associated health providers involved in my medical treatment and health care

Disclosure for Research and Quality assurance to improve community healthcare such as cancer registry, implant registry and nation audits

By checking this, I agree to register as new patient with Dr. Ramesh Iyer