DORSAL SLIT REGISTRATION

QUEENSLAND’S

Trusted Circumcision & Vasectomy Clinic

SMS ENQUIRIES 0409 632 693 OR PHONE 07 2103 2322

It is important to know details about your medical history, as it forms part of vital records for your treatment with Gentle Procedures Clinic. Please note we require every field to be completed to ensure a complete record.

The information you provide is confidential and will be handled per our Privacy Policy.

We kindly ask you to complete this form 48 hours before your appointment as the information is reviewed by Dr Hunt.

By completing, signing & submitting the form, you are making an informed consent to the procedure being performed on the date of your appointment.

If you do not consent to some or all of the sections, do not complete or submit the form and contact our office to discuss 07 2103 2322

Please note most sections on this form require an entry; if you do not have the answer, please enter n/a for not applicable. If you do not have your Medicare card, please enter the number 0 in each cell.

Dorsal Slit Registration Form

Step 1 of 3

Name
This field is for validation purposes and should be left unchanged.
Patient Information:
Name*
First Name: Last Name:
Date of Birth*
Day
Month
Year
Medicare Card Number:*
Your medicare number should be 10 digits long
Medicare Ref: (Left of name)*
Medicare Expiration Date mm/yyyy*
Department of Veteran Affairs
DVA Card Number
DVA Card Expiry Date
Day
Month
Year
DVA Card Colour
- White
- Orange
- Gold
Healthcare Card Number (if applicable)
Healthcare Card Expiry Date
Day
Month
Year
Card Type
- New Start
- Disability
Pensioner Card Number (if applicable)
Pensioner Card Expiry Date
Day
Month
Year
Pensioner Card Type
- Aged
- Disability
Address*
Residential Address or suburb State ZIP / Postal Code
Phone Number:*
Email Address:*
Emergency Contact Name*
First Last
Emergency Contact Phone*

0409 632 693

Trusted Circumcision & Vasectomy Clinic

DORSAL SLIT REGISTRATION

Dorsal Slit Registration Form

Step 1 of 3

Patient Information:

General Doctor Details:

Allergies:

Medical History (Tick Appropriate)

Dorsal Slit Consent | Please Ensure To Read And Tick Each Point

Complications May Include:

CONSENT / PRIVACY / RELEASE OF INFORMATION:

Clinic Locations

Gentle Procedures Spring Hill

Gentle Procedures UNDERWOOD

Gentle Procedures TOOWOOMBA EAST

AFTERCARE SUPPORT (Text Preferred)

Phone:

FAX:

PATIENT REGISTRATION

ONLINE SERVICES

POLICIES & PROCEDURES