New patient form

Complete your details before your first appointment.

Thank you for trusting Adelaide Urology Care to look after your urological care. If you are a new patient, we will kindly ask you to complete a New Patient Form prior to your first appointment. This can be completed in the convenience of your own home or in the rooms prior to your appointment.

New Patient Form

Personal details

First Name

Last Name

Date of Birth

Occupation

Contact details

Mobile

Home Phone

Street Address

Suburb

Medicare & health fund

Medicare No.

Medicare Reference No.

Medicare expiry

Private Health Insurance

Yes

Private Health Fund Name

Private Health Fund No.

DVA card colour

Gold

White

DVA Card No.

Next of kin

Next of Kin

Next of Kin Contact No.

Next of Kin Relationship

Referral & GP

Referring Doctor

Name of usual GP

Name of GP Practice

Please list other specialists involved in your care

Medical history

Past Medical History

Medications

Allergies

Privacy & consent

All information collected by this practice will be used for providing healthcare. Collection, utilization and storage of this information will be compliant with the 2001 Health Records Act.

Consent

I consent to Adelaide Urology Care collecting my health information.

I consent to correspondence by SMS or email.

Have a referral or a question?

Our team is here to help. Ask your GP for a referral to Adelaide Urology Care, or call us.

Call (08) 8119 0961 Contact us