PATIENT REGISTRATION
PATIENT DETAILS
Title
Please select
Dr
Miss
Mr
Mrs
Ms
Prof
First Name
Last Name
DOB
Day
Month
Year
Phone
Home
Mobile
Occupation
Employer
Email
Marital
Please select
Defacto
Divorced
Married
Separated
Single
Widowed
Country of Birth
Are you of Aboriginal or Torres Straight Islander descent?
Yes
No
ADDRESS
Street Address
Address
Suburb
State
Please select
ACT
NT
NSW
QLD
SA
TAS
VIC
WA
Postcode
Postal Address
Use street address?
Yes
No
Address
Suburb
State
Please select
ACT
NT
NSW
QLD
SA
TAS
VIC
WA
Postcode
NEXT OF KIN / EMERGENCY CONTACT
Name
Phone
Relationship
Please select
Mother
Father
Sister
Brother
Son
Daughter
Uncle
Aunt
Nephew
Niece
Cousin
Grandfather
Grandmother
Employer
Spouse
Domestic Partner
Friend
Other
Foster Father
Foster Mother
Stepfather
Stepmother
ENTITLEMENTS
Medicare
Medicare Card No
(10 digit card number e.g. 1234567890)
Reference No
(the number next to your name)
Expiry Date
(e.g. 01/2099)
Pension Card
Pension Card No
Expiry Date
(e.g. 01/2099)
DVA
DVA File Number
Expiry Date
(e.g. 01/2099)
Card Colour
White
Gold
WORKCOVER
Is this attendance a work related injury?
Yes
No
Employer
Address
Telephone
Contact Name
Claim No
FAMILY HISTORY
e.g. Diabetes, blood pressure, cancer, depression, cause of death etc.
Mother
Father
Siblings
Other
Children
ALLERGIES
Do you have any allergies?
Yes
No
Year
Cause of allergy
Type of reaction
ALCOHOL / TOBACCO
Do you currently smoke?
Yes
No
Number of cigarettes a per day?
Have you ever smoked?
Yes
No
For how long?
How Many?
If ceased, when (year)
Do you drink alcohol?
Yes
No
What type and quantity?
PAST MEDICAL & SURGICAL HISTORY
eg. Blood pressure/asthma/ diabetes/operations/depression,etc.
CONSENT
I acknowledge that my medical record will be held in a secure electronic &/or hard copy form and the practice may use electronic transmissions in the management of my medical record and care. I understand that the record will only be assessed by approved users during the course of their work. I also acknowledge that I maybe sent reminder /recall letters or SMS as part of this practices preventive health measures. The practice is an accredited teaching practice for undergraduates and postgraduates. I acknowledge that I may decline their presence during a consultation. The practice also participates in clinical research, accreditation and quality assurance activities that may require access to records by approved users. The practice undertakes to not use any information that would identify your health record individually without your consent except where legally required or requested with your consent including transfer or copying medical records. The practice conforms to the requirements of Privacy Legislation and the practice policy on privacy available perusal on request from Reception.
Patient Signature:
Clear Signature
(Please use mouse or stylus to sign below.)
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