New Patient Registration - Paradigm Urology

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Paradigm Urology

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03 4440 1940

Paradigm Urology

New Patient Registration

We welcome new patients to our practice to provide the following information prior to their first appointment. This information will be sent directly to our practice.

If you prefer to print this form out and bring it to your appointment, please download it here.

New Patient Registration (PDF)

New patient registration form

Are you an existing patient of Dr Tony Makris?(Required)

Yes

No

Name

Prefix First Last

Date of Birth

MM slash DD slash YYYY

Phone (Preferred)(Required)

Phone (Home)

Phone (Work)

Postal Address

Street Address Address Line 2 Suburb State Post Code

Next of Kin (or Emergency Contact)

Name

First Last

Phone

Relationship to Patient

Healthcare Information

Medicare Number

Sequence Number

Do you have private health insurance (hospital) cover?

Yes

No

Health Fund Name

Membership Number

Usual GP (if different from referring doctor)

Are you on any of the following Concession Cards?

Pension Care Card

Health Care Card

Veterans Affairs Card

Pension Card Number

Expiry Date

Health Care Card Number

Expiry Date

Veterans Affairs Card Number

Card Colour

Allergies and Existing Medications

Provide details of any allergies to medications.

Shellfish

Yes

No

Iodine

Yes

No

Do you have diabetes?

Yes

No

Are you on any blood thinning medication?

Astrix

Aspirin

Warfarin

Other

If yes, diet controlled or medications?

Please list all medications you currently take including: name of drug, dosage in mg, how often taken

Δ

03 4440 1940

reception @ paradigmurology.com.au

03 7048 9008

Mon-Fri
9.00am - 4.30pm

78A Barkly Street
BENDIGO VIC 3550

Echuca Consulting Suites,
25 Francis Street ECHUCA

Kyneton Consulting Suites,
65 Simpson Street KYNETON

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Our Team
Conditions
Treatments
Patients
- New Patient Registration
- Patient Forms
Referrers
Contact
03 4440 1940

Our Team
Conditions
Treatments
Patients
- New Patient Registration
- Patient Forms
Referrers
Contact
03 4440 1940