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About
Services
For Patients
Resources
- Downloads
- Patient Registration Form
FAQs
Reviews
Contact & Locations

About
Services
For Patients
Resources
- Downloads
- Patient Registration Form
FAQs
Reviews
Contact & Locations

Menu

About
Services
For Patients
Resources
- Downloads
- Patient Registration Form
FAQs
Reviews
Contact & Locations

To Register

Complete & Return Our Online Form …

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To Register Your Details, Please Complete & Submit Our Online Form

CLICK HERE FOR PDF FORMAT OF REGISTRATION FORM

New Patient Registration

Title

First Name:

Surname:

DOB:

Address:

Home Phone:

Mobile:

Occupation:

Email Address:

Next of Kin:

Relationship:

Number:

General Practitioner:

Medicare:

Ref No:

Private Health Fund:

Membership No:

Concession/Pensioner:

Yes No

TAC/Workcover:

Yes No

DVA:

Yes No

Blood Thinners:

Diabetic:

Type 1 Type 2

Pacemaker or Stent:

Drug allergies:

Other Medications:

PRIVACY POLICY

To comply with the Privacy Laws (Privacy Act Amendments – Private Sector – Act 2004) your agreement to the following statement is required: I agree to allow the Doctors of Plastic & Reconstructive Surgery Melbourne access to all relevant information regarding my medical conditions. I understand that PRSM may be required to forward information about my medical condition or history to other health care providers.

PAYMENT POLICY

For all consultations and any treatment provided in our private rooms, the fee is payable on the day of service. For all cosmetic patients, any surgical procedure booked in hospital requires full payment 10 days prior or the surgery will be cancelled.

PHOTOGRAPHY POLICY

All patients that have treatment and surgery with Plastic & Reconstructive Surgery Melbourne have before, during and after photos taken. This is an important part of a patient’s medical care and will be kept in your confidential medical record. I agree that the images can be used for the following purposes:

Placed in my medical record & shared with treating medical practitioners as required.

Yes No

Book An Appointment

Click the Appointments button to book in and our team will be in touch soonest to confirm the details.

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12 Mitcham Road, Donvale, VIC 3111
03 9988 2888
Operating Hours: Monday - Friday: 9.00AM - 4.30PM

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