VCSA New Patient Registration Form

Patient Details (AS PER MEDICARE CARD )

First Name *

Last Name *

Known as

Date of Birth (dd/mm/yyyy) *

Contact Details

Street Address *

Suburb (Enter as one word, no spaces) *

Postcode *

Mobile No *

Work No

Home No

Email Address *

Postal address is the same as street address

Postal Address *

Emergency Contact

First Name *

Last Name *

Relationship *

Contact Number *

General Practitioner (GP) Details

Name *

Telephone No *

Practice Name *

Address *

Referring Doctor Details (Tick if you have been refered by a Doctor or specialist that is not your GP)

Name *

Telephone No

Practice Name

Address

Medicare/Insurance Details

Private Health Fund *

YesNo

Fund Name *

Member No *

Medicare Number (10 digits) *

Reference No *

Expiry Date (01/mm/yyyy) *

Concession Card Holder *

YesNo

Concession Card Type

Health Care CardPensioner Concession CardDVAOther

Card type

Card Number

Please advise *

Vascular Symptoms

Please inform whether the following vascular symptoms apply to you:

Unhappy with appearance of legs *

Yes No

Bulging veins *

Yes No

Small, purple/red, 'spider' or 'thread' veins *

Yes No

Painful or aching legs *

Yes No

Restless legs *

Yes No

Leg cramping *

Yes No

Swollen legs or ankles *

Yes No

Itching associated with veins *

Yes No

Skin ulcer associated with veins *

Yes No

Rash / eczema surrounding ankle area *

Yes No

Bleeding associated with veins *

Yes No

Vulval veins *

Yes NoNot applicable

Pelvic heaviness *

Yes NoNot applicable

Heavy periods *

Yes NoNot applicable

Other (please specify):

Recent Ultrasound History

Have you had an ultrasound of your veins in the last 12 months? *

YesNo

If yes, where was this performed?