Patient Registration Form

Please complete prior to your consultation

Dr Len Kliman – Gynaecologist
*PLEASE NOTE THIS IS NOT THE HOSPITAL ADMISSION FORM

First Name(Required)

Last Name(Required)

Date of Birth

Street Address

Address Line 2

City

State

Postcode

Country

Home Phone Number

Mobile Number(Required)

Email(Required)

Medicare Card Number

Do you have Private Health Cover?

Yes

Are you a Veteran Affairs Gold Card Holder?

Yes

Gold Card Number

Referring GP/Specialist Details:

Attach your referral (Optional)

Max. file size: 256 MB.

Please list current Medications

Next of Kin: First Name(Required)

Next of Kin: Last Name(Required)

Next of Kin Contact Number(Required)

Please list any known allergies

FEES: Consultation fees are payable of the day of consultation. Any other fees associated with surgery will be discussed with you prior to the surgery. In the instance that your account is referred to a Debt Collection Agency, additional fees will be incurred. Should your health insurance reject your hospital claim for any reason, you will be liable for all costs incurred. It is prudent to speak to your Health Insurer prior to any hospital admission to ensure you have an appropriate level of cover.(Required)

I have read and understood the above

Authorisation for the release of medical information including results (eg: Pathology, Imaging, reports) of investigations to Dr Len Kliman as necessary for my treatment plan.(Required)

I do authorise

I do not authorise

Patient Check List

Referral information: You will need to obtain a GP referral for your initial consultation.
Make an appointment: Your consultation will take place in our consulting rooms at the Epworth Freemasons Day Procedure Centre
Initial Consultation: During this consultation a full medical and surgical history will be taken and a medical examination may be performed. Blood tests and an ultrasound may be required. This initial appointment takes approximately 30 minutes.
Treatment Options: Dr Kliman will have a detailed discussion about treatment options that are available for your specific condition so that an informed decision can be made.
Urgent Care: During business hours, please contact our office on 94192372. After hours for urgent matters, Dr Kliman can be contacted via his paging service on 9387 1000. For emergencies we recommend that you attend the Epworth Emergency Department or call 000.

For any questions, please call us on 03 9419 2372

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