New Patient Registration

info@dralsalihi.com.au

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New Patient Registration

Please note: items marked * indicate mandatory fields.

Personal details

Title*

First Name*

Last Name*

Preferred name

Occupation

Date of Birth*

Contact Details

Address*

Suburb*

State*

Postcode*

Email*

Home PhonePlease enter phone number with area code included. No spaces please. eg. 0298765432

Work PhonePlease enter phone number with area code included. No spaces please. eg. 0298765432

Mobile Phone*Please enter mobile number. No spaces please. eg. 0412345678

Preferred Contact Method *

Memberships

Medicare Number 10 Digits

Medicare IRN1 digit next to cardholder's name

Medicare Expiry

Private Health Fund Nameeg. HCF, NIB, Bupa

Are you a member of the Department of Veterans Affairs (DVA)?*YesNo

Emergency contact

Partnner Name

Partner Phone

Next of kin Name Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432

Relationship to next of kin

Next of kin Phone

Medical Information

Referring Doctor Name

Referring Doctor PhonePlease enter mobile or phone number with area code included. No spaces please. eg. 0298765432

Medical History*Yes – I do have relevant medical history, detailed belowNo – I do not have relevant medical history

Specialist details

Specialist Name

Speciality

Specialist Medical Practice Name

Specialist Phone

Consent to release medical information

I give my consent to Dr Salwan Al-Salihi, or their agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care.

I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Dr Salwan Al-Salihi, or their agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010.

For more information view our Patient Information Privacy Statement on this website.

Yes, I consent to the above.

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