New Patient Registration Form

Contact Details/Personal

Full Name

Gender

Date of Birth

Cultural background

AboriginalTorres strait IslanderAustralianOther

Home Telephone

Work Telephone

Mobile Telephone

I consent to be contacted by SMS on this number

YesNo

Email

I consent to be contacted by email at this address

YesNo

Address

Postal Address

Next of kin

Emergency Contact

Occupation

Allergies

Please record any allergies or sensitivities you may have below

Other Details

Referring GP- Name, Phone, Address

Medicare & health Fund/Pension/Veterans Affairs/Workcover

Medicare Number

Ref

Expiry Date

Veterans Affairs Card

YesNo

Type

GoldWhiteYellow

Dept. of Veterans Affairs Number

Health Fund Name

Membership Number

Health Care Card Number

Expiry Date

Pension Card Number

Expiry

Is this a Workcover Claim?

Yes No

Claim Number:

Insurer Name

Is this a Dept. Of Defence Claim?

Yes No

Patient Consent

By signing below, I confirm that:

I give my consent for this practice to collect, store, and manage my personal and health information in accordance with the Privacy Act 1988.
I understand that this information may be shared with other healthcare providers involved in my care, when necessary, for my ongoing treatment and wellbeing.
I consent for health practitioner to use artificial intelligence software to help transcribe clinical notes
I consent to being contacted by the practice regarding my healthcare (e.g. appointment reminders, test results) via phone, SMS, or email.
I understand that I can withdraw or update my consent at any time by notifying the practice in writing.

Signature

Name

Signature

Draw signature|Type signatureClear

Date