Patient Registration FormWe request that all new patients complete the form below. Patient Details Name * First Name Last Name Date of Birth * MM DD YYYY Mobile Number * Email Address * Occupation Medical History Do you have any medical conditions, or previous surgeries? Please outline below. Write "none" if appropriate. * Do you have any of the following conditions? High blood pressure Pacemaker Heart problems Diabetes Kidney problems Allergies Please list your medications below. Write "none" if appropriate. * Next of Kin Details Name * First Name Last Name Relationship to Patient * Friend, Family, Partner Phone Number * Medicare and Health Insurance Medicare Card Number * Reference Number * Expiry Date * Private Health Insurance? * Yes No Fund Name Fund Number Concessions Aged or Disability Pension Number Expiry Date Dept Veteran's Affairs Card Number Expiry Date Card Colour White Gold Health Care Card Number Expiry Date Referrer Details Referrer Name (e.g. GP) * First Name Last Name Practice Name * Practice Phone * Practice Address * How did you hear about us? We require your consent to collect personal information about you. Please read this information carefully and mark the relevant fields below. This 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 and a full medical history so that we may properly assess, diagnose, treat and be proactive in your healthcare needs. This means we will use the information you provide in the following ways: - Administrative purposes in running our medical practice. - Billing purposes, including compliance with Medicare and Health insurance Commission requirements. - Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals. - Disclosure to other doctors in the practice, locums and by Registrars attached to the practice for the purpose of patient care and teaching. Please let us know if you do not want your records accessed for these purposes, and we will note your record accordingly. - Disclosure for research and quality assurance activities to improve individual and community health care and practice management. You will be informed when such activities are being conducted and given the opportunity to “opt out” of any involvement. - I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling the patient information. - I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me. - I understand that I may request access to my health records. This must be in writing and I must provide proof of my identity prior to the request being authorised. Charges may be incurred with this request. Your request will be handled within 45 days of the letter of request being received and/or within 7 days of your payment being received. - I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained. - I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure that I notify this practice of. I have read, understand and give my consent for the information above. * I consent to the above I do not consent to the above Today's Date * MM DD YYYY Thank you!
