Patient Registration Form

Patient Details

First Name *

Last Name *

Date of Birth

Age

Address

Address Line 1

Address Line 2

City

State

Postcode

Home Phone (inc area code)

Mobile Phone

Work Phone

Email Address *

Medicare Number

Ref

Expiry

Workcover Claim

Private Health Fund

Membership Number

DVA

Gender

Marital Status

Next of Kin

Phone Number

Regular GP

Practice Name

Phone Number

Do you have any allergies, if YES, please list:

Are you currently on any regular prescription medications (ie Warfarin, Xarelto etc)?

Do you regularly take over the counter Vitamins (ie Fish Oil capsules etc)?

Do you suffer from DiabetesYesNo

If yes, what dose of injectable insulin are you using?

If the patient is under 18 years of age please provide the following information:

Parent / Guardian Name

Parent / Guardian Medicare No

Parent / Guardian Ref

Medicare Expiry

Parent/Guardian DOB

PRIVACY INFORMATION & CONSENT

As a patient of our medical practice, we require you to provide us with your personal details and a full medical history, so that we may properly assess, diagnose, treat and be proactive in your health care needs. We aim to protect the privacy of your health and personal information. You can request a copy of our practice privacy policy, which includes information about the collection, use and disclosure of your health information. We require your consent to collect your personal information, and for its use in the following ways:

Administrative purposes;
Billing purposes (including compliance with Medicare and Health Insurance Commission requirements);
Disclosure to others involved in your healthcare. This includes your treating Doctor and other Specialists outside this medical practice. This may occur
through referral to other doctors, or for medical tests and in the reports or results returned to us following referrals;
For research and quality assurance activities to improve individual and community health care and practice management. Only information that does
not identify you is used in these circumstances;
To comply with any legislative or regulatory requirements, such as notifiable diseases;
For reminders and recalls which may be sent to you regarding your health care and management.

By signing this privacy information and consent document, I consent to having my information transmitted electronically to authorised third parties. Additionally, I consent to the handling of my information by this practice for the purpose set out above.

Name *

Signature *

Use your mouse or finger to draw your signature above

Date *