Patient Registration

First Name *

Last Name *

Date of Birth *

Email Address *

Phone Number *

Emergency Contact

Home Address *

WorkCover Claim Number

Employer *

Date of Injury *

Brief Description of Injury *

Regular GP and address

Hypertension Diabetes (Type 1/2) Heart Disease Stroke / TIA Asthma / COPD Kidney Disease Liver Disease Cancer (past/ongoing) Bleeding/Clotting Disorder Thyroid Disease Osteoporosis Depression / Anxiety Chronic Pain Current or Past Smoker None of the above

Other Conditions

Current Treatment or Medications

Additional Notes

I consent to Premier Health Australia collecting and using this information for the purpose of providing healthcare services. I understand that this information will be treated confidentially in accordance with healthcare privacy regulations.

Register as a Patient

Personal Information

Contact Information

WorkCover Information

Past Medical History

Additional Information

Registration Error