Admission Form

Please fill out the form below and when complete, click on the submit button.

Title:	Mr Mrs Ms Miss
Surname:		Given Names:
Address:		State:	Postcode:

Phone (H):		Phone (M):
Phone (W):		Sex:	Male Female
Marital Status:		D.O.B

Next of Kin:		Relationship:
Phone:
Second Contact:		Relationship:
Phone:

Health Insurance Fund:
Member/DVA no:		Medicare no:
No: next to name:		Valid to:
Pension no:		Expiry:
Safety Net Card:

GP Details:		Phone:

Country of Birth:		If Australia, State:
Torres Strait Islander/Aboriginal:	Yes No	Occuptation:

Have you been a patient at Penninsula Oncology before: Yes No
If yes when:

Patient Declaration: By submitting this form I agree to be admitted to Peninsula Oncology Centre in full knowledge of my obligation that all fees charged during my admission will be paid. I consent to my in-patient accounts being forwarded directly to my private health fund. I release the Centre from any claims for whatever loss/theft/damage of my personal property which may occur whilst a patient at the Peninsula Oncology Centre. I confirm that I have been informed with regards to the use and disclosure of my personal health information and hereby give informed consent for the use of this information by the Peninsula Oncology Centre.