UNIVERSITY HEALTH SERVICE – PATIENT DETAILS FORM

PLEASE PRINT
TITLE Prof  A/Prof  Dr  Mr  Ms  Mrs  Miss  Other  _______

FAMILY NAME
(SURNAME)
FIRST NAME(S) Preferred Name
(PERSONAL NAME(S))

DATE OF BIRTH
/ / / Male  Female 
dd / mm / yyyy
Aboriginal Torres Strait Islander Aboriginal/Torres Strait Islander
ETHNICITY
Australian Non-Indigenous OR Other please specify___________________

Please enter your address, phone number and email that UHS can use to contact you on about
matters which may be confidential & or private including SMS reminders and messages.

ADDRESS (line 1)

ADDRESS (line 2)
 NO MAIL TO BE SENT
CITY/SUBURB POSTCODE TO THIS ADDRESS

PHONE NUMBERS MOBILE W ORK HOME

EMAIL

EMERGENCY CONTACT Surname________________________ First Name ___________

NAME & PHONE No Phone Number ___________________________
Their relationship to you  PARENT  PARTNER SIBLING FRIEND
STUDENT (AUSTRALIAN CITIZEN/RESIDENT)  UNDERGRADUATE  POSTGRADUATE
STUDENT (INTERNATIONAL)  UNDERGRADUATE POSTGRADUATE DEPENDANT
STAFF  ACADEMIC  GENERAL OTHER
OCCUPATION:
AUSTRALIAN CITIZENS / RESIDENTS

MEDICARE No Reference No. (to left of your name):

(10 digits) Valid to (dd/mm/yyyy):
HCC No (Centrelink/Pension Card): Expiry (dd/mm/yyyy):

INTERNATIONAL STUDENTS and their DEPENDANTS

ALLIANZ OSHC EXPIRY DATE

POLICY No (dd/mm/yyyy)

IF YOU DO NOT HAVE A VALID MEDICARE OR ALLIANZ OSHC CARD, PAYMENT MUST BE MADE AT TIME OF
CONSULTATION BY CASH, EFTPOS OR CREDIT CARD.

I CONFIRM THE ABOVE INFORMATION IS CORRECT

NAME/SIGNATURE: DATE:
(dd/mm/yyyy)
Email completed form to: uhs.reception@sydney.edu.au