Title*
Name*
Surname*
Date of Birth(dd/mm/yy)*
Gender*
Marital Status*
SingleMarriedDefactoSeparatedDivorcedWidowed
Occupation
Home Address
Postcode
Postal Address
Postalcode
Telephone number
Work number
Mobile number
Email*
To enable us to tailor your healthcare, please complete the following
Do you identify as Aboriginal or Torres Strait Islander origin?*
NoYes
Country of birth
Year arrived in Australia
Language spoken
To be able to process the fee for service in relation to your consultation, we require the following questions to be completed. Please note that all cards must be valid for the date of consultation.
Do you have a Medicare card?*
Medicare card number
Medicare reference number
Medicare card expiry date
Do you have a Pension/Health Care Card?* NoYes
Pension /Health care card number
Expiry date
Private health fund?*NoYes
Name
Number
Pension, Health Care Card, or Veterans Affairs number (if applicable)
Type of Veterans Affairs card
In the event of an emergency, we need to know who the best person for you is that we can contact. Please provide us with your next of kin details.
Next of kin
First Name
Last Name
Relationship to you
Emergency Telephone Number
Emergency Work Number
Emergency Mobile Number
So that our general practitioner can better understand the status of your health, please advise if you have had or currently have any of the following health conditions.
Operations
Chronic illnessYesNo
If yes please include information
Are you on any regular medications?YesNo
If yes, list more information:
Do you have any allergies and intolerances or are you sensitive to drugs or dressings?YesNo
List allergies and intolerances to medications
Describe your reaction
List regular medications and doses, and complementary medicines and doses
Our practice uses a reminder system to improve the quality of your healthcare. We aim to confirm appointments via telephone or SMS. The practice sends reminders by mail or telephone for procedures such as vaccinations, pap test, and other health review
I consent to being contacted with reminders as part of the quality improvement activities at this practice. NoYes
We are committed to protecting the confidentiality of your personal information to enable us to provide you with our health services and any related communications ( for example to manage your appointment booking )
Please consent to our handling of your personal information in accordance with our privacy policy
I agree to the terms. NoYes
Signature
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