New Patient Registration Form | Tahmoor Family Medical Practice

Next of Kin
Name*
Relationship to you*
Phone (Mobile)*
Phone (Home)
Phone (Work)
Emergency Contact
Name*
Relationship to you*
Phone (Mobile)*
Phone (Home)
Phone (Work)
Do you identify as someone from a culturally and/or linguistic diverse background?*
- Yes
- No
If yes, Please indicate ethnicity*
To assist with health initiatives - are you Aboriginal or Torres Strait Islander?*
- Yes - Aboriginal
- Yes - Torres Strait Islander
- Yes - Aboriginal & Torres Strait Islander
- No

Our practice undertakes research, professional development, and quality assurance/improvement activities to improve patient care. All people accessing personal health information for this purpose have signed a written confidentiality agreement.
I consent to my health record being reviewed and uploaded to My eHealth Record as a part of the quality improvement activities in this practice.*
- Yes
- No
I give permission for my personal information to be collected, used and disclosed as described in this practice policy. I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.*
- Yes
- No
Our practice uses a reminder system to improve the quality of your health care. The practice sends reminders by mail or telephone for procedures such as vaccinations, pap smears and other health reviews.*
- Yes
- No
I consent to being contacted with reminders by sms/phone/email*
- Yes
- No

Patient Details

Relation to you (e.g., mother, grandfather, sibling)	Condition/s