Patient registration Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Date of Birth GenderFemaleMaleUnspecifiedOtherGender other: Address Street Address Suburb Post code Email* Home phone Mobile phone* Work phone Emergency contact name First Last Emergency contact relationship Emergency contact phone Do you require an interpreter? Yes No Interpreter language Medicare number Position Expiry date Pension card Veteran's affairs number Name of Health Care Fund: Membership Number: Health Care Fund Level of Cover Top Cover Basic Cover Extras Cover (ONLY) Name of referring Dr First Last Name of GP (If different to Referring Doctor) First Last Have you had or are you suffering from: Blood pressure: Yes No Heart problems: Yes No Stroke: Yes No Diabetes: Yes No Lung: Yes No Do you smoke? Yes No Any other Health Problems:Previous Operations :Medications (please name):Allergies:PasswordDue to Federal Privacy Laws, we request all patients supply a password for their file. This means, that if you, or anyone on your behalf phones for results, they will be required to disclose the password prior to any information is released about the patient, and information will not be provided if this password is incorrect. Please contact the office if you have any questions about this. NB: Chose something straightforward and easy that you will remember (eg. Pet’s name, Mothers maiden name etc.) SMS remindersOur practice is able to send appointment reminders. Would you like to receive these reminders as an SMS? Yes No Phone number SignatureDate MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
