Kooweerup Regional

Health Service
(INSERT BRADMA LABEL)

Admission Form

Admission Date: Admission Time:

Department for Admission:
Title:  Mr  Mrs  Ms  Miss  Master  Other
First Name:
Surname: Previous Surname:
Gender:  Man  Woman  Self-Described Date of Birth: / /
Are you Aboriginal or Torres Strait Islander Origin?
 Aboriginal  Torres Strait Islander
 Aboriginal and Torres Strait Islander  Not Aboriginal or Torres Strait Islander
Country of Birth: Religion:
Preferred Language: Interpreter Required:  Yes  No  Not Stated
Marital Status:
 Single  De Facto  Divorced  Married  Separated  Widowed  Other
Residential Address:
Postcode:
Home Phone Number: Mobile Phone number:
NEXT OF KIN DETAILS
Name: Relationship:
Address:
Postcode:
EMERGENCY CONTACT DETAILS
Name: Relationship:
Home Phone Number: Mobile Phone Number:
General Practitioner:
Clinic Name:
Address:
Postcode:
Phone Number:
Pension Number: Expiry Date:
INSURANCE DETAILS
 Public – complete Medicare details  TAC – complete TAC details below
 DVA – complete DVA details below  WorkCover – complete WorkCover details below
 Private – Complete Health Fund details below
Medicare Number Position on Card: Expiry Date: / /
DVA Number: Plan Type:  Gold  White  Orange
Health Fund Name: Level of Cover:  Top  Basic
Membership Number: Private Claim Form completed:  Yes  No
WorkCover/TAC Details:
Claim Number: