PATIENT REGISTRATION ONLINE FORM

OPENING MAY 2025

All patients please fill in the form below and press submit to register as a patient with Wound Care Melbourne.

One of our friendly team will respond to you within 2 business days.

PATIENT REGISTRATION FORM

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PERSONAL DETAILS

Date of Birth
Address

PRIVATE HEALTH INSURANCE | TAC | WORKCOVER

Do you have Private Health Insurance?
If Yes - Do you have hospital cover?
Are you claiming through WORKCOVER
Are you claiming through TAC

IF PATIENT UNDER 14 - PARENT/GUARDIAN DETAILS

PATIENT MEDICAL INFORMATION

Have you had recent surgery
Is your wound related to recent surgery
Type of surgery performed
Wound location
Side of wound if applicable:
How long have you had wound problems for:
Who has been providing treatment for your current wound:
Are you currently on Antibiotics:
Are you a Smoker:
Are you a Diabetic:
Do you currently take Blood Thinners:
Do you have any Medicine Allergies:
Have you previously had Deep Vein Thrombosis/Pulmonary Embolism:
Have you previously had a Heart Attack:
Do you have a Stent or Pacemaker:
Have you previously had a Stroke or TIA:
Have you had previous problems with Anaesthetics:
Have you had imaging done:
If Yes - What imaging has been taken:
Imaging provider (if applicable)
How did you hear about WOUND CARE MELBOURNE

FEES & PRIVACY POLICY & CONSENT

Your consultation fee will be advised when making your appointment. If you are eligible for Medicare rebates, on receipt of your fee payment your claim will be submitted directly to Medicare.
I am the guardian of a patient under the age of 14
Consent
I understand that this practice handles personal information in accordance with the National Privacy Principles enshrined in the Privacy Act 1988 (Commonwealth) and as outlined in the Privacy Statement. I consent to the handling of my information by this practice, including via email, fax and postage, for the purpose of providing quality health care, associated administrative and billing purposes, and disclosure for research and quality assurance activities. We take reasonable steps to protect information and your privacy when transmitting your information. We will use post, secure messaging, facsimile, and email, to transmit your information, on request or as appropriate. You acknowledge that email is not a secure form of transmission. We are unable to provide clinical advice to patients via email. I also give permission for medical information to be obtained from any other source in order to help with my treatment.
Date / Time
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You can attach up to 5 files.

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