New Patient Registration And Medical History Sheet

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Date: …. / …. / ….
Date:
…….............
Time:
…….............
New Patient Registration and Medical History Sheet
USE BLOCK LETTERS PLEASE
Dr M Sargeant
Dr E C Wong
Dr P Khinda
Dr. J. Chan
Dr D Oberklaid
Dr J. Wadsley
Dr M. Fonti
Dr J.Kirwood
Dr P Dissanayake
Dr D Pytharoulios
Dr A. Andrews
Title: _____ NAME: ________________________________________ __________________________
(Surname)
(First Name)
(Mr / Mrs / Ms / Miss / Dr.)
ADDRESS: _____________________________________________________________________________________
Suburb: ____________________________________________________
Postcode: _____________
D.O.B: ____ / ____ / ________
Occupation: ______________________________________________
Contact Phone No. (h): ___________________ (w): _____________________ (mob.): _____________________
)
(We send SMS appointment reminders – tick if you do NOT wish to receive.
Email Address__________________________________________________________________________
(We may contact you via this email address for health reminders, newsletters or health promotion activities
)
Tick if you do NOT wish to be contacted via email.
Aboriginal and Torres Strait Islander:
 Aboriginal
 Torres Strait Islander
 Aboriginal & Torres Strait Islander
Medicare Number: ____ ____ ____ ____ ____ ____ ____ _____ ____
____
Ref No: ____
Valid to: ____ / ____
Centrelink Pensioner Concession Card No: ______________________________________
Valid to: ____ / ___
Centrelink Health Care Card No:
_______________________________________ Valid to: ____ / ____
Veteran Affairs Pensioner Concession Card
No: ________________________________
Valid to: ____ / ____
Credit Card Details for Patients without a Medicare Card
We will require your Credit Card details before seeing a doctor.
Your details will be securely held in accordance with the Health Privacy Principles and National Privacy Principles
as set out in the Health records Act (Victoria 2001) and the Privacy Act (Commonwealth 1988).
Credit Card details:
Visa / MasterCard / Amex __ __ __ __
__ __ __ __
__ __ __ __
__ __ __ __ Valid from: __/__to: __/__
Please see front reception staff at the end of your consultation for payment processing.
Patients Consent:_________________________________
Date:____________
Signature
Emergency Contact:
Name: ___________________________ Contact No: ___________________Relationship: ______________
Next of Kin:
Name: ____________________________Contact No: ______________________ Relationship: ______________
(If different from Emergency contact)
How did you hear about us?
 Website
 Via a friend or relative, worker  via on line  Yellow Pages online Saw the sign Other (please specify)
Patients attending with new injuries will be required to pay the private practice fees on the day and seek reimbursement back
from Workcover there may be out of pocket costs, registered companies excepted
Claims to TAC will only be accepted once the claim has been verified.

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