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New Patient

Registration

Our new patient registration form is designed to streamline your onboarding process, making it quick and easy to gather essential information. Fill out the form to ensure we have all the details needed to provide you with the best possible care.

"*" indicates required fields

Step 1 of 4

Patient Details

Title*

Surname*

Given Name/s*

Date of Birth*

DD slash MM slash YYYY

Gender*

If other, please specify*

Marital Status*

Medicare No.*

Ref No.

Expiration Date

Pension, Health Care Card or DVA White/Gold Card No:

Expiration Date

Occupation

Employer

Home Address*

Postcode*

Postal Address*

Postcode*

Email*

Phone (Home)

Phone (Work)

Phone (Mobile)*

Next of Kin

Name*

Relationship to you*

Phone (Mobile)*

Phone (Home)

Phone (Work)

Emergency Contact

Name*

Relationship to you*

Phone (Mobile)*

Phone (Home)

Phone (Work)

Do you identify as someone from a culturally and/or linguistic diverse background?*

Yes

If yes, Please indicate ethnicity*

To assist with health initiatives - are you Aboriginal or Torres Strait Islander?*

Yes - Aboriginal

Yes - Torres Strait Islander

Yes - Aboriginal & Torres Strait Islander

Health Questionnaire

Allergy to medication or food?*

Yes

Unknown

If yes, Please specify*

Smoker Status*

Never Smoked

Ex-Smoker

Smoker

If Ex-Smoker, Please specify year quit

If Smoker, Please specify no per day

Alcohol Intake*

Nil

Yes

If yes, please choose standard drinks/per*

Day

Week

Month

No of drinks*

Recreational Drugs*

Yes

Regular Medications*

Nil

Yes

If yes, Please list below any medications and their doses if known – include over the counter medications and supplements*

Current/Previous Medical Conditions*

Nil

Yes

If yes, please tick any that apply*

Asthma

Diabetes Type 1/Type 2

Heart Attack (MI)

Stroke/CVA

Pacemaker

DVT

Emphysema

Depression and/or Anxiety

Cancer

HIV/AIDS

Hepatitis A / B / C

Epilepsy

Other

Please specify Cancer type

If other, please specify*

Family Medical History*

Nil

Yes

If yes, Please list below*

Relation to you (e.g., mother, grandfather, sibling)

Condition/s

Our practice undertakes research, professional development, and quality assurance/improvement activities to improve patient care. All people accessing personal health information for this purpose have signed a written confidentiality agreement.

I consent to my health record being reviewed and uploaded to My eHealth Record as a part of the quality improvement activities in this practice.*

Yes

I give permission for my personal information to be collected, used and disclosed as described in this practice policy. I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.*

Yes

Our practice uses a reminder system to improve the quality of your health care. The practice sends reminders by mail or telephone for procedures such as vaccinations, pap smears and other health reviews.*

Yes

I consent to being contacted with reminders by sms/phone/email*

Yes

Name

This field is for validation purposes and should be left unchanged.