Patient Registration Patient detailsName(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last D.O.B(Required)Sex(Required)Address(Required) Street Address Suburb Postcode Home phoneMobile phone(Required)Email(Required)(Please note: all receipts and patient correspondence will be sent to this email address) Referring DrUsual GPMedicare NumberIndividual reference numberExpiry datePrivate Health Fund:Membership numberDept. Vets Affairs NumberTypeHealthcare / Pension CardExpiryEmergency contactsNamePhoneRelationship to youDo you consent to us giving this person your results and appointment information? Yes No MedicationsDo you take any of the following? Warfarin Plavix Aspirin Pradaxa Anti-inflammatories Other Other medication:Medical conditions – Do you have any of the following: Heart condition Yes, medicated Yes, pacemaker Yes, stents inserted No Diabetes Yes, type I Yes, type II No Epilepsy Yes, medicated Unmedicated Allergies Penicillin Latex Anaesthesia Other Other allergy:Disabilities Hearing impaired Vision impaired Mobility Intellectual Other Other disability:UPLOAD YOUR REFERRALFile Drop files here or Select files Max. file size: 128 MB. YOUR PRIVACY AND MEDICAL INFORMATIONThis medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details so that we may properly access, diagnose, and treat your health care needs. This means that we will use the information for administrative purposes, billing, disclosure to others involved in your health care; including specialists and other treating doctors outside this practice and disclosure to other doctors in the practice including locums to assist in your medical care. This practice may occasionally be involved in research and quality assurance activities to improve individual and community health care and practice management. All information is de-identified. If you wish to opt out of any research undertaken by the clinic please inform your doctor. We wish to assure you that at all times your health information is treated with utmost confidentiality. I have read and understood the above information regarding my medical information.Name(Required)Signature(Required)Date(Required) MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
