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Arterial Disorders
Varicose Veins
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Patient Registration

- Step 1 of 4

Name *

First

Last

Date of Birth *

Phone Number *

Email Address *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Name of General Practitioner *

First

Last

GP Practice Name

Referring doctor name (if not your usual GP)

Emergency Contact Name *

First

Last

Emergency Contact Phone Number *

Emergency Contact Relationship *

Medicare or DVA Number *

Medicare Reference Number

Medicare expiry

Do you have private health insurance? *

Level of Coverage *

Knowing your level of health insurance prior to your appointment will allow us to provide a more accurate summary about your surgical options and out of pocket expenses. For vascular surgery, silver level and/or above is usually required. Often, your level of coverage can be found within your account portal or health fund phone application. Our most frequently used item number is 32523 (minimally invasive treatment for varicose veins).

Health Fund Name

Health Fund Number

Pre-existing conditions

High Blood Pressure
Previous heart attack/chest pain
High cholesterol
Previous stroke or mini stroke (TIA)
Diabetes
Kidney Disease
Blood clotting problems
Problems with anaesthesia (or family history)
Cancer
Chronic infections
Other (please describe below)

Other

Please tell us about any other significant health problems, or past medical history you may have.

Current medications and natural therapies *

If none, record "none" in text field

Do you have any allergies? *

Allergies

List allergies you are aware of, and if you are aware of any allergies to contrast.

Did you have particular issues or concerns you would like to address during your consultation?

Do you have any of the following?

Advanced care directive
Medical power of attorney

How did you hear about us? *

Do you consent to Melbourne Vascular Associates submitting claims to medicare on your behalf? *

Yes
No

Melbourne Vascular Associates will often need to submit invoices on your behalf for services provided, or claims for reimbursement.

Melbourne Vascular Associates sometimes utilises artificial intelligence to write your consult notes and correspondance letters from time to time. This allows you to leave our practice with a copy of your consultation notes, and improves speed and efficiency of communication with your other health care providers. No identifying information or recordings are kept. Do you provide your consent? (visit https://www.lyrebirdhealth.com/au/patient for more information) *

Yes
No

Referral Upload

Click or drag files to this area to upload. You can upload up to 5 files.

Upload a copy of your referral here. If you do not have a copy of the referral please leave blank. If you are accessing this page from your phone, clicking on the icon will allow you to take a photo of the referral with your phone's camera. You can upload up to 5 seperate pages or images.

Contact

t: (03) 8362 3780

f: (03) 8677 1755

e: admin@vascularsurgeons.com.au

Hospital Locations

Private

Warringal Private
Epworth Eastern
Knox Private
Holmesglen Private

Public Affiliations

Austin Health
Eastern Health

Consulting Locations

Warringal Private

Shepparton Private

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