New Patient Registration Form

Contact Details/Personal

Full Name

Address

Postal Address

Gender

Date of Birth

Home Phone

Work Phone

Mobile Telephone

I consent to be contacted* by SMS on this number:

Yes No

I consent to be contacted* by email at this address:

Yes No

Next of Kin

Full Name

Tel:

Relationship:

Emergency Contact

Full Name

Tel:

Relationship:

Cultural Background

Aboriginal Torres Strait Islander Australian

Other Details

Referring GP

Full Name

Phone

Address

Medicare & health Fund, Pension, Veterans Affairs, Workcover:

Medicare Number

Reference No:

Expiry Date

Veterans Affairs Card

Yes No

Gold White Yellow

Dept. of Veterans Affairs Number:

Health Fund Name

Membership Number:

Health Care Card

Expiry Date:

Pension Card Number

Expiry Date:

Is this a Workcover Claim?

Yes No

Claim Number

Insurer Name

Is this a Dept. Of Defence Claim?

Yes No

Allergies

Upload Referrals/Correspondence form

Patient Consent

By Submiting the form below, I confirm that:

I give my consent for this practice to collect, store, and manage my personal and health information in accordance with the Privacy Act 1988.
I understand that this information may be shared with other healthcare providers involved in my care, when necessary, for my ongoing treatment and wellbeing.
I consent for health practitioner to use artificial intelligence software to help transcribe clinical notes
I consent to being contacted by the practice regarding my healthcare (e.g. appointment reminders, test results) via phone, SMS, or email.
I understand that I can withdraw or update my consent at any time by notifying the practice in writing.