New Patient Registration Form Please ensure you complete all information required. If you’d preferĀ to download, print and fill out, you can find the links below. Registration Patient Details (PDF) Registration Patient Profile (PDF) First Name Last Name Address City State Post Code Email Address Date of Birth Home Phone Mobile Phone Medicare Number Medicare Reference No. Medicare Expiry Private Health Fund Name Private Health Fund Number Referring Doctor Name Referring Doctor Suburb Next of Kin Name Next of Kin Contact No. Next of Kin Relationship General Practioner Name General Practioner Suburb Medical History Medical History Yes I have relevant Medical History No I do not have relevant Medical History Existing Diagnosed Conditions Previous Operations Other Information I give my consent to Dr Jo Schoeman, or his 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 Jo Schoeman, or his agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. I give my consent to Dr Jo Schoeman, or his 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 Jo Schoeman, or his agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. Yes I consent to the above 7 + 6 = Submit