Patient Registration

    Patient Registration


    Name*:

    First Name:

    Last Name:

    Address*:
    Street Address:

    Street Address Line 2:

    City:

    State/Province:

    Please write down your country if you are outside of Australia:

    Postal / Zip Code:

    Date of Birth:

    Occupation:

    Home Phone:

    Work Phone:

    Mobile Phone*:

    Private Health Insurance Fund:

    Fund Membership Number:


    Medicare Number:

    Medicare Reference Number:
    (IRN or individual reference number)

    Medicare Expiry Date:

    Health Care Card Number (HCC):

    HCC Expiry Date:


    Email Address:

    DVA Gold Card Number:

    TAC Claim Number:

    Referring Doctor:

    General Practitioner:

    Next of Kin:

    Emergency Contact Number:

    Condtions & Terms*:

    Patient Signature (Required)*:


    Cardiac Risk Factors
    NoFamily History of Coronary Heart DiseaseHigh CholesterolHigh Blood Pressure

    Cardiac Risk Factors - Smoker
    CurrentEx SmokerNever

    Cardiac Risk Factors - Diabetes:
    NoType 2- diet controlledType 2- oral medicationsType 2- insulin requiringType 1Maturity onset diabetes of the young (MODY)Impaired glucose tolerance

    Past Cardiac History:

    Medications:

    Medications Allergies:

    Referral Urgency:
    Urgent (<1 Week)Semi Urgent (<3 Week)Non Urgent (>3 Week)

    Requested Cardiologist:
    Next AvailableSpecific Cardiologist

    Specific Cardiologist: (Skip if choose 'Next Available')
    Dr Christopher Allada: Cardiologist and Interventional Cardiologist (Adult)Dr Kris Nowakowski: Cardiologist and Echocardiography Specialist (Adult)Dr Ahmad Farshid: Cardiologist and Interventional Cardiologist (Adult)Dr Ala Mustafa: Paediatric CardiologistDr Davinder Pal Singh: General Cardiologist (Adult)

    Other Specialist / Health Care Provider:
    Dr Jaydeep Mandal: General Physician (Adult)

    Dr Ahmad Farshid Consulting Clinic:
    Marketplace Gungahlin, Big W Mall, First Floor, Suite 13, 30-33 Hibberson Street Gungahlin, 2912

    Dr Ala Mustafa Consulting Clinic:
    Lidia Perin Medical Centre, 1/12 Napier Close, Deakin, 2600

    Preferred Clinic:

    Lidia Perin Medical Centre, 1/12 Napier Close, Deakin, 2600Marketplace Gungahlin, Big W Mall, First Floor, Suite 13, 30-33 Hibberson Street Gungahlin, 2912Next availiable


    Referral Request:
    ConsultationEchocardiogram24 Holter MonitorDevice CheckElectrocardiogram (ECG)Telehealth ConsultationStress Echocardiogram24 Hour Blood Pressure Monitor4 Day Holter Monitor7 Day Holter MonitorOther

    If you select other, please write down your specific referral request:

    Device Brand: (if device check has been chosen)

    MedtronicBiotronicAbbottSorin

    Condtions & Terms*:


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