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Sunshine Coast Ear, Nose & Throat Surgery
Sunshine Central Medical & Diagnostic Centre
Level 1, Suite 7b, 3 Nicklin Way
MINYAMA QLD AUSTRALIA 4575

Phone: 07 5478 4359
Fax: 07 5478 4362

New Patient Details
Surname

Dr/Mr/Mrs/Miss/Ms/Mast:
First Name:

Medicare No.

 Exp date:
Postal Address: Health Fund: Date joined:
Home Phone Number: Mobile Number:
Dept. Vet Affairs No: Next of kin:
Date of Birth:
Occupation: Work Phone Number:
Your usual family Doctor:
Do you smoke: Yes No If yes, how many per day?  
Do you have a history of: (please indicate)
Heart Disease Yes No Lung Disease Yes No
Bleeding Disorder Yes No Blood Pressure Yes No
Strokes Yes No Diabetes Yes No
Stomach Ulcer Yes No Cancer Yes No
Are you on any medications at present? (please indicate)
 
Please list any allergies?
 
Have you had any previous operations? If yes, what were they and when?
 
How will you settle your account today: (please circle)
Cash, Cheque, Credit Card, EftPOS, Veterans' Affairs
Signature (patient/parent/guardian):
Date:
Medical Information Release: