Patient information

    Name

    Medicare Number

    Street

    Suburb

    Postcode

    Date of Birth (DD/MM/YYYY)

    Phone contact number

    E-mail

    Gender

    Are you:

    Are you an existing patient of EK Medical?

    Date (DD/MM/YYYY) you are booked in for your vaccine (Please leave this answer blank if you have not been allocated an appointment)

    Are you Aboriginal and/or Torres Strait Islander?

    Name of Next of Kin

    Relationship

    Phone contact number

    Date

    For Guardians Only

    Guardian/substitute decision-maker’s name