• Surgeon Profile
  • Services
  • Patient Information
    • Make an Appointment
    • Patient Registration
    • e-Admission
    • COLONOSCOPY INSTRUCTIONS – (Morning)
    • COLONOSCOPY INSTRUCTIONS – (Afternoon)
    • Discharge Information following Surgery
    • Discharge Information following Surgery for Banding of Haemorrhoids
    • Links
  • Contact Us
Make an Appointment New Patient Registration e-Admissions

Openning Hours

Monday to Thursday
9am to 4PM
Excluding public holidays

If you need to pick up paperwork or prep, please call our rooms ahead of time as we may close periodically

Phone: 6214 3275

New Patient Registration Form

Mr Srini Yellapu New Patient Registration

Medical care requires full knowledge of patient health information by all member of the medical team. To ensure quality and continuity of patient care, patient's health information must be shared with other healthcare providers/diagnostic facilities from time to time. Some information about patients is provided to Medicare and Private Health Fund, if relevant, for legal and medical rebate reasons. If you have any concerns, please contact the Practice.

Name(Required)
Date of birth(Required)
Address(Required)
Referring Doctor(Required)
Family Doctor
Do you have a Medicare Card?(Required)

Do you have private health insurance?(Required)
Hospital Cover over 12 months
Level of Cover

Do you have overseas health insurance?(Required)

Do you have Pension of Health Care card?(Required)

Are you covered by Department of Veterans Affairs?(Required)

Workers Compensation Claim(Required)

Medical History & Current Conditions

Do you have any allergies?(Required)
Or any bad reactions to Endone, Morphine, Latex tapes for example.
Do you take any blood thiners?
Are you Diabetic
Current Diabetes Treatment

Do you have a lap band?
Do you have any fluid in there at the moment?
Are you taking any weight loss injections?

Rheumatic Fever
Heart Condition
Chest Complaints
Asthma
Bone Disease
Epilepsy
Arthritis
HIV / AIDS
Reflux
Ulcer
Hernia
Diabetes
High Blood Pressure
Kidney Disease
Liver Disease
Bleeding Disorders
Blood Transfusions
Hepatitis
Radiotherapy
Drug Addiction
Depression
Anxiety
If you are female could you be pregnant?
COVID 19 Vaccinated
Please list.
Are you currently taking ANY medications?(Required)
In the past 5 years have you had any major operations?(Required)
Do you drink alcohol?
Do you smoke?
Do you use any mobility aids?(Required)
Type of Mobility Aid:

Emergency Contact Information

Emergency Contact Person(Required)

Authorisation

IMPORTANT, by clicking the submit button below you are indicating that you are the Patient or Parent / Guardian of the Patient and legally authorised to complete this form and agree to our terms and conditions below in relation to how this information may be used.
Patient Information Policy Consent(Required)
Medical care requires full knowledge of patient health information by all member of the medical team. To ensure quality and continuity of patient care, patient's health information must be shared with other healthcare providers/diagnostic facilities from time to time. Some information about patients is provided to Medicare and Private Health Fund, if relevant, for legal and medical rebate reasons. If you have any concerns, please contact the practice.
Make an Appointment New Patient Registration e-Admission
© 2025 Mr Srini YellapuPrivacy Policy