Patient Registration Form - Northern Blood & Cancer Care

Patient Registration

Patient Registration & Medical History Form

Please complete the patient registration & medical history form before your visit. You may complete the online form below or download a printable forms.

Download Printable Form

Personal Details

First name

Preferred name

Middle name

Surname

Sex

Date Of Birth

Preferred language

Address

Suburb

Postcode

Phone (Home)

Phone (Mobile)

Phone (Work)

Occupation

Marital status

Weight & Height

Weight (kg)

e.g. 78kg

Height (cm)

e.g. 175cm

Reason For Appointment

Next of Kin / Emergency Contact

Next of kin name

Relationship

Next of kin phone

General Practitioner

GP name

GP phone

Clinic name & suburb

If your GP above was not the referrer, please provide details of your referring doctor below:

Referrer name

Referrer phone

Referrer clinic name & suburb

Other Treating Specialists

You may add up to 3

Specialist name

Specialist phone

Clinic name & suburb

Add Remove

Consultation Fees

Consultation Fees are to be settled at the time of your appointment. Payment can be made by cash or credit/debit card (American Express, Amex and Diners not accepted). For your convenience, we can process the Medicare rebate at the time of consultation. A copy of our fee schedule can be sent to you upon request.

Medicare number

Medicare ref number (Number next to your name)

Medicare expiry

Health fund name

Health fund membership number

Health Care card number

Health Care card expiry

Pensioner card number

Pensioner card expiry

Veteran Affairs number

Veteran Affairs expiry

Work Cover insurer

Work Cover claim number

TAC claim number

If you are human, leave this field blank.

Haematology

Medical Oncology

Cancer Therapy

Specialist Physicians

Clinical Services