• Doctor's Dashboard

Register a Warfarin Patient

* = mandatory field

Doctor Details


Dr Name: *

QML Dr Code or Provider No.: *

Is the patient aware of and accepts the initial registration fees? *

Are you the primary care Doctor?*

If no, please nominate a primary care doctor who can manage routine patient issues*

Surgery Address: *

Suburb: *

Contact Phone Number: *

Email Address: *

 

Patient Details


If this patient has previously been rejected from the QML Pathology Warfarin Control Program please do not continue to complete this form. Please contact the call centre on 1300 795 355 to clarify if the patient will be accepted.

Patient's First Name: *

Patient's Last Name: *

Patient's Date of Birth: *

Patient's Gender: *

Patient's Address: *

Patient's Suburb: *

Patient's Postcode: *

Patient's Phone/Mobile Number:
(ph. no. must include 10 digits)
*

Second Contact Number (For patient, relation or neighbour)
(ph. no. must include 10 digits) :