New Patient Registration Form

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New Patient Registration Form
The Doctors and Staff at this clinic are committed to whole patient care. This includes preventative and ongoing care. To assist us
maintain your wellbeing we ask you to complete this form. All information collected about you will remain confidential.
Title: ______ First Name: __________________________Family Name: __________________________Date of Birth: __ /__ /__
Gender: ______ Medicare Number: ___ ___ ___ ___ ___ ___ ___ ___ ___
___ Reference Number: ___ Exp: ___ /___
Please Circle Pension/Health Care Card Number: _____________________________________________ Exp: ___ /___/___
DVA (Veteran Affairs) Gold/White: ________________________________________ Exp: _________
Address: ______________________________________________Suburb:_________________________ Postcode: ___________
Home Phone: _____________________ Mobile: ______________________________ Business No: _______________________
E-mail Address: ___________________________________________________________________________________________
Next of Kin: __________________________________Gender: ________Relationship: ____________Phone: ________________
Same as Next of kin
Emergency Contact: ___________________________Gender: ________ Relationship: _
Phone: ________________
Please circle Are you Aboriginal/Torres Strait Islander Yes/No
Country of Birth: ___________________ Year of Arrival: ________Self-identified ethnicity:_______________________________
Please list current Medications: _____________________________________________________
Not taking any medications
Please list any Allergies: _____________________________________Reaction: ______________________________________
Please list any operations/previous illness: ___________________________________________
No significant medical history
Do you currently smoke? YES/NO
Are you an ex smoker? YES/NO
Do you drink alcohol? YES/NO
How many per day? __________
Quit Date __________
How often? __________
Have you ever had or have any of the conditions below? If Yes please circle
Diabetes Kidney disease Asthma
Bowel Cancer Breast Cancer High blood Pressure Heart Problems Epilepsy
Other:__________________________________________________________________________________________________
Is there a family history of any of these conditions? If yes please state relationship
Diabetes Kidney disease Asthma
Bowel Cancer Breast Cancer High blood Pressure Heart Problems Epilepsy
Relationship to you (Mother, Father, Grandparent):______________________________________________________________
Who do you live with? ________________________ How many children do you have?____ Marital Status______________
_
Occupation: _______________________________ How did you hear about us?_______________________________________
Are you planning to attend Ballarto medical centre for ongoing care. DO NOT tick if you are visiting.
PRIVACY
We must obtain your consent for messages to be left on your telephone or mobile answering or message bank regarding matters involving your
health. Do you agree? YES/ NO
REMINDER SYSTEM
Our practice provides our patients with preventative care and early case detection reminders e.g.: immunisations, annual health checks, skin
checks and pap smears. Do you agree for reminders to be sent to you by mail or SMS
YES / NO
This clinic participates in SMS reminders for some appointments and health initiative reminders. Please circle if you DO NOT wish to be part NO
CONSENT
I Consent to the collection, use and handling of my information by the practice for the purposes set out above.
For further information please refer to our collection and use statement displayed at reception or ask for a copy of our Privacy Policy.
Name:____________________________________________ Signature:______________________________________ Date:______________
OFFICE USE ONLY. Entered Pracsoft ................. Entered MD..................

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