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PATIENT REGISTRATION

PATIENT DETAILS

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ADDRESS

Street Address
Postal Address

NEXT OF KIN / EMERGENCY CONTACT

ENTITLEMENTS

Medicare
(10 digit card number e.g. 1234567890)
(the number next to your name)
(e.g. 01/2099)
Pension Card
(e.g. 01/2099)
DVA
(e.g. 01/2099)

WORKCOVER

FAMILY HISTORY

e.g. Diabetes, blood pressure, cancer, depression, cause of death etc.

ALLERGIES

Year Cause of allergy Type of reaction

ALCOHOL / TOBACCO

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.


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