New Patient Registration

Personal details
Contact details
Please enter phone number with area code included. No spaces please. eg. 0298765432
Please enter phone number with area code included. No spaces please. eg. 0298765432
Please enter your full mobile number. No spaces please. eg. 0412345678
Memberships
10 Digits
1 digit next to cardholder's name
eg. HCF, NIB, Bupa
Emergency contact
Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432
Medical Information
Please enter mobile or phone number with area code included. No spaces please. eg. 0298765432
Including over the counter medications
Drugs or other causes

If there are any other specialists that require clinical information, please fill the information below.

Specialist details
Consent to release medical information

I give my consent to Hagley Vascular (Dr Daniel Hagley), or their agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care.

I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Hagley Vascular (Dr Daniel Hagley), or their agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010.

For more information view our Patient Information Privacy Statement on this website.