New Patient Registration Form

Step 1 of 4

Patient Details

Title*

Surname*

Given Name/s*

Date of Birth*

Gender*

If other, please specify*

Marital Status*

Medicare No.*

Ref No.

Expiration Date

Pension, Health Care Card or DVA White/Gold Card No:

Expiration Date

Occupation

Employer

Home Address*

Postcode*

Postal Address*

Postcode*

Email*

Phone (Home)

Phone (Work)

Phone (Mobile)*

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

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

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

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

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

I consent to being contacted with reminders by sms/phone/email*

Yes

CAPTCHA

Monday	8:30 AM – 7:00 PM
Tuesday	8:30 AM – 7:00 PM
Wednesday	8:30 AM – 7:00 PM
Thursday	8:30 AM – 7:00 PM
Friday	8:30 AM – 7:00 PM
Saturday	9:00 AM – 2:00 PM
Sunday	9:00 AM – 2:00 PM

Patient Details

Next of Kin

Emergency Contact

Health Questionnaire