Registration Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Cover

We can admit you to a private hospital only if you have Hospital Cover

Hospital Cover

Extras Only

Don't know

Level of Cover

Check with your insurance company if unknown

Gold

Silver

Bronze

Don't Know

Is this your usual GP?

Yes

No

Have you every been admitted to hospital?

Yes

No

Do you live alone?

This is important after discharge from hospital

Yes

No

Do you smoke?

Yes

No

Are you an ex-smoker?

Yes

No

Do you drink more than two alcoholic drinks per day?

Yes

No

Are there any illnesses that run in the family?

Yes

No