Patient Information Form "*" indicates required fields Select a DoctorDoctors*Please SelectFirst AvailableDr Rajan RehanDr Christopher YuDr Kaivan VaidyaDr Chinmay KhandkarDr Christopher KocxDr Jayant RavindranDr Jamie ChamPersonal Information To assist in your first appointment please complete this form for our admin team.Title* Mr. Ms. Mrs. Miss Name* Given Name Surname Preferred NameDate of Birth Gender Male Female Consent I do not wish to receive remindersIf you do not wish to receive information including appointment reminders via SMS Please tickAddress* Street Address Address Line 2 Suburb State / Province / Region Phone (H)Phone (W)Phone (M)*Email* OccupationMedicare No.*Expiry Date*RefHealth FundMembership No.Dept. of Vet. Aff. No.DVA Card Colour: Clear White Gold Orange Who is responsible for your account? Self Others - Please provide details below Name Given Name Surname Address Street Address Address Line 2 Suburb State / Province / Region Emergency Contact InformationName* Given Name Surname Phone: (H)Phone: (W)Phone: (M)Relationship to Patient*Medical Practitioner InformationReferring Dr*Usual GPReferral Information: Referrals provided by a General Practitioner will last for a period of 12 months unless your Doctor has specified "ongoing" or "indefinite" referral. After 12 months it is essential for you to provide a new referral from your GP to meet Medicare requirements. If you have been referred by a Specialist Physician or through a Public Hospital your referral will only last for a period of three(3) months.Have you seen any other cardiologist? Yes No Doctor's namePractice nameContact numberFax numberAuthorised consent to request and release medical recordsConsent* “I hereby authorise and request One Heart Centre to receive and release personal medical information and results from or to Medical Practitioners on my behalf.“I confirm that the above information I have provided is true, complete, and accurate.Patient / Gurdian Signature*Max. file size: 128 MB. Please upload your signature hereDate Medical Release I provide consent for One Heart Centre to obtain any relevant test results and correspondence relating to my medical history. I provide consent for results and correspondence to be sent to my referring and usual doctors as well as other medical professionals involved in my care when requested. I provide consent for messages to be left with immediate family members (eg, appointment confirmation). I understand the Consultation Fees are due for payment on the day of Consultation (gap payments are not accepted). Accounts can be processed immediately in our rooms so that you receive your Medicare rebate directly into your nominated account normally within 24 hours. Signature*Max. file size: 128 MB. Please upload your signature hereDate*
