Patient Registration Form

CONFIDENTIAL INFORMATION

Personal Information

Title

Date of Birth

Surname

Given Name

Address

Suburb

Postcode

Telephone No. (Home)

Telephone No. (Work)

Telephone No. (Mobile)

Email Address

Occupation

Medicare No.

Ref No. (digit to the left of card holder’s name)

Expiry Date (mm) (yy)

Have you held your private health insurance hospital cover for more than 12 months
YesNo

If you have selected yes to having private health insurance, please fill out the following details. Otherwise if you have selected no, please move onto the Next of Kin / Emergency Contact section.

Private Health Fund Name

Private Health Fund Member No.

Member since (mm) (yy)

Veterans Affairs Card No. (if applicable)

Card Color

Next of Kin / Emergency Contact

Full Name (Next of Kin / Emergency Contact)

Relationship

Telephone No. (Next of Kin / Emergency Contact)

GP details if different from referring doctor

Full Name (GP)

Telephone No. (GP)

Address (GP)

Paediatric/Special Needs Patients

(only complete this section if the patient is aged less than 18 or unable to legally give consent, otherwise move onto next section)

Date of Birth of Primary Medicare Card Account Holder

Ref No. (Digit to left of card holder’s name)

I am a legal parent or guardian of the patient and capable of giving consent to any surgical procedures if necessary
YesNo

Name/contact phone of legal parent/guardian

Pre-existing Medical Conditions

Pre-existing Medical Conditions (List All)

Medications (List All, including fish oil, herbal supplements etc)

Allergies
YesNo

List Allergies (including latex, medical tape etc)

Advance Care Directive Plan

Do you currently have one in place

Privacy & Financial Consent

(a copy of our privacy policy is available on request)

The information provided on this form is collected for the purpose of providing comprehensive health care. This data will be retained on your patient record and kept confidential. Your patient record may, however, be disclosed to third parties involved in your care and under certain circumstances:

where required by law
when requested by another medical practitioner/hospital including emergency medical care

I understand that I will incur out-of-pocket expenses and that fees are due and payable on the day of consultation. A 20% surcharge + GST may apply to accounts not paid on the day of consultation.

Please click yes to confirm you have read and understood the Privacy Statement and Financial Consent.
I have read and understood the Privacy Statement and Financial Consent:
Yes