SPLEEN AUSTRALIA: Registration
STEP 1 of 6
If you need help with completing this registration call the Spleen Australia on 03 9076 3828 or if you are a Queenslander - call 1800 SPLEEN (775336)
INFORMATION ABOUT REGISTERING:
1. The process takes approximately 5 minutes
2. You will need vaccination dates (if possible)
3. You can only enter YOUR INFORMATION once
4. If you leave your computer for more than 15 minutes – you may lose the information you have entered
5. Confirmation of registration will occur after completing final page
To close, press the ESC key or click outside this box.
I am providing information about:
myself
as a medical provider for a patient
as a parent/guardian for a patient less than 18 years of age
Has this patient given permission for their health information to be forwarded to Spleen Australia?
Yes
No
If the patient lives in Queensland, and has
not
given permission to forward their information you can provide us with their name and contact details and Spleen Australia will contact the patient to ask if they would like to join the registry.
FULL NAME of person filling in this form
Phone number
Pager (if applicable)
Please complete the personal details of the patient below. When complete click the next button. If you need to go back a page click the previous button.
Press TAB to move from box to box.
Personal Details of Patient
First Name
Middle Name
Family Name
Gender
Male
Female
Indeterminate
Date of Birth
dd/mm/yyyy
Medicare Number
Address 1
Address 2
Suburb
Postcode
State
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Please provide at least 2 of the contact details below.
Home Phone
example: (03) 9999 8888
Mobile
example: 0400 999 888
Email Address
No Email Address
Do you have an iPhone/iPad (for Spleen App)?
Yes
No
Don't Know
Are you [is the person] of Aboriginal or Torres Strait Islander origin?
No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, Both Aboriginal & Torres Strait Islander