Registration Form

PLEASE FILL OUT THIS FORM FOR A NEW PATIENT WHO IS SEEING EITHER OUR GP OR DERMATOLOGIST. 

PLEASE FOLLOW THIS INSTRUCTION ONLY IF THE PATIENT IS SEEING OUR DERMATOLOGIST:

IF THE PATIENT IS A MINOR THEN THE PARENT OR GUARDIAN NEEDS TO FILL OUT THE PAYER’S DETAILS FORM.  PLEASE SEND THE REFERRAL FORM TO INFO@GLASSSTREETCLINIC.COM.AU OR FAX (03) 9351 0974 OR UPLOAD IT.  IF YOU CANNOT DO THIS THEN PLEASE GET YOUR DOCTOR’S CLINIC TO DO IT FOR YOU.  THANK-YOU.

GP or Specialist Name: (required)

Select (required)

First Name (required)

Middle Name

Surname (required)

Date Of Birth (dd/mm/yyyy)(required)

Sex (required)

Your Email

Phone Number (Required)

Mobile

Address (Required)

Suburb (Required)

Postcode (Required)

Medicare (Required 10 digits)

Medicare Ref (Required (Digit in front of name))

Centrelink Concession (Required)

Concession Card Number

Concession Card Expiry (dd/mm/yyyy)

Private Health Insurance (Required)

Private Health Insurance Coverage (Required)

Aboriginal or Torres Strait Islander (Required)

Country Of Birth (Required)

Family Background (Country Of Origin) (Required)

Occupation (Required)

Next Of Kin Surname (Required)

Next Of Kin Firstname (Required)

Next Of Kin - Relationship to you (Required)

Next Of Kin - Phone Number (Required)

Emergency Contact Surname

Emergency Contact Firstname

Emergency Contact - Relationship to you

Emergency Contact - Phone Number

Allergies / Past Medical History & Operations:

Current Medications:

Any known infectious diseases (Required)

Please Give More Details If "Other" was selected

CONSENTS – In keeping with the PRIVACY ACT LAWS proclaimed in 2001, we require your written consent with regard to the following. Please Select Yes or No:


I give consent for Medical information to be obtained by my doctor for the purpose of my medical treatment and passed on to third parties eg, specialists for the purpose of further treatment (Required):

I give consent for medical reminder letters to be sent to me at the preferred mailing address (Required):

I give consent for medical reminder via SMS to be sent to me at the provided mobile number (Required):

I give consent to release RESULTS to my designated Relative / Carer on behalf (Required):

Relative/Carer Name (Required):

Please Fill Out The Following For The Dermatologist:

Referring Doctor

Provider Number

Date Of Referral (dd/mm/yyyy)

Period Of Referral (12 Months for a GP or 3 Months for a Specialist)

Please select reason(s) for Dermatologist visit:

NoneEczemaRashItchinessSkin CheckHair LossAcnePsoriasisOther

Please Give More Details If "Other" was selected

Please upload the referral letter from your Doctor: