Patient Registration – Wodonga Specialist Obstetricians & Gynaecologists

Patient Details
Title *	Miss Mrs Ms
First Name *
Surname *
Middle Name
Preferred Name *
Previous Surname	(e.g. Maiden Name)
Date Of Birth *	DD/MM/YYYY
Address
Street *
Suburb/ Town *
Postcode *
Phone & Email
Home Phone
Work Phone
Mobile Phone *
Email Address *
Confirm Email Address *
Medicare Details
Prefix No *	(The number next to your name)
Medicare No *
Expiry Date *
Private Health Fund
Do You Have Hospital Cover? *	Yes No
Name of Fund
Membership No
Are you covered for Pregnancy and Birth?	Yes No
Health Care/ Pension Card Details
Expiry Date
Health Care/ Pension Card No
Usual GP
Name *
Clinic *
Location *
Occupation
Your Occupation
Next of Kin
Relationship *
Name *	This is the person we will contact should we be unable to contact you.
Mobile Phone *
Consent
Private Patients Only	I have read and agree to the IMC Patient Claim Consent & Declaration
Privacy Consent *	I have read and agree to the Privacy Information & Consent Form
Spam Check
Captcha *	10 − 9 = ?

PLEASE NOTE
Public Patients – should you require surgery at Albury Wodonga Regional Health Service (Wodonga Hospital) as a Medicare patient, then the surgery will probably be performed, at least in part, by the trainee gynaecologist under the consultant’s supervision.

Please read important information about Patient Privacy

Patient Details

Address

Phone & Email

Medicare Details

Private Health Fund

Health Care/ Pension Card Details

Usual GP

Occupation

Next of Kin

Consent

Spam Check