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Varicose Veins
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Patient Registration

- Step 1 of 3

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? *

Health Fund Name

Health Fund Number

Do you have an aged pension card?

Aged Pension Card 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?

Referral Upload

Click or drag a file to this area to upload.

Upload a copy of your referral here. If you do not have a 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.

How did you hear about us? *

Contact

admin@vascularsurgeons.com.au

T: +61 3 8362 3780

F: +61 3 8677 1755

A: 80 Yarra St Heidelberg VIC 3084

Hospital Locations

Private

Epworth Eastern
Knox Private

Public Affiliations

Austin Health
Alfred Health
Eastern Health

Consulting Locations

“Alone we can do so little, together we can do so much.” — Helen Keller