Patient Registration

Please do not leave blanks.

Title *

Surname *

Given Names *

Preferred Name

Date of Birth *

E-mail Address

Home Phone

Work Phone

Mobile *

Address *

Suburb *

Post Code *

Post Address (if different to above)

Marital Status

Occupation

Next of Kin / Partner's Name *

Relationship *

NOK Contact Home Phone *

NOK Contact Work Phone

NOK Contact Mobile

Health Insurance Fund (Hospital cover) *

Number *

Medicare number *

Ref. Number (before your name) *

Select as Appropriate

Expiry date

Number

Referring Doctor *

Usual GP *

How did you hear about us?

All personal information in the clinic is handled in accordance with the practice’s privacy policy and consistent with the privacy legislation.

Dr Amir is involved in teaching other specialists and gynaecologists in training. Occasionally de-identified clinical material including digital images obtained in surgery may be used.

I acknowledge and have read the practice privacy

Privacy Policy