Patient Registration Form

Patient Details

GP Details

Next of Kin/Emergency Contact

Medicare Details

Private Health Fund Details

Please indicate if you have experienced any of the following conditions:

Heart problemsDiabetesKidney problemsHigh Blood PressureCholesterolStrokeCancerBleeding problemsClotting problemsDeep Vein Thrombosis (DVT)Varicose veins

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Privacy Policy

To provide a high standard of health care we need to collect personal information from our patients. All persons accessing your health information are bound by confidentiality. Please do not hesitate to discuss any concerns related to the privacy of your personal information with your clinician. We ask for your consent to discuss your case with other health care providers should that be required to assist in your treatment:

I consent to the use of my personal health information by Yarra Vascular Surgeons and other health providers involved in my medical treatment and health care

I consent to the disclosure of my personal health information by the above named practice to other health providers directly or indirectly involved in my personal health care or medical treatment

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