New Patient Registration Form

As a patient of our medical practice we require you to provide us with your personal details and full medical history, so that we may properly assess, diagnose, treat and be proactive in your health care needs. This form complies with the RACGP Standards for general practices (5th edition). This means your personal health information is kept private and secure, as required by federal and state privacy laws. You can request a copy of our privacy policy from reception, which includes information about the collection, use, and disclosure of your health information.

Please notify us promptly of any changes in your contact details. Accurate contact details help us identify you and your medical records, and allow us to contact you promptly about tests and results

Title

First Name

Middle Name

Last Name

Preferred Name

Date of Birth *

Address

Suburb

State

Post Code

Phone number - home

Phone number - mobile

Phone number - work

Ethnicity

Australian, non-Aboriginal or Torres Strait IslanderAboriginalTorres Strait Islander Other

If other, please specify

Email Address

Occupation

Medicare Number *If you do not have a Medicare Card, please insert N/A

Reference *

Expiry date

Head of Family (Reference 1 on Medicare Card) - this is required for children 14 years and younger so we can process your Medicare rebate

Full Name

Date of Birth *

Other card

PensionSeniors Health Care CardHealth Care Card

Card number

Expiry date

DVA Card

GoldWhite

QSM Number

White card conditions

Next of Kin

Telephone number

Relationship to you

Emergency Contact

Telephone number

Relationship to you

I consent to the practice collecting my information to be used 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 my healthcare 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 referrals.
Disclosure to other doctors in the practice, locums, etc. attached to the practice for the purpose of patient care and teaching.
For the purpose of sending appointment reminders for scheduled appointments.
Accreditation and quality assurance activities
For research to improve individual and community health care and practice management. Note - only de-identified information is usually used. Should information that will identify me be required, the practice will inform me and provide me with the opportunity to “opt-out” of any involvement.
To comply with any legislative or regulatory requirements e.g. notifiable diseases.
for sending my information to the relevant national and state health registers e.g. immunisation register, cervical screening register. I understand I can withdraw my consent to participate in these registers at any time.

I understand that it is important that the practice is able to contact me and may use any contact details provided by me including SMS to my mobile phone number as well as the use of my email address (when all other avenues of contact have been exhausted). SMS and email are also used for the purpose of recalls, reminders, preventative health messages, and on occasion information about services.

Please let us know if you wish to Opt-Out of SMS contact

Please let us know if you wish to Opt-Out of email contact

I understand that the practice is required to send de-identified, aggregated data to the Department of Health on a quarterly basis. I understand that it is might right to opt-out of data about myself being included.

I request to opt-out of my data being included in data sent to the Department of Health

Please confirm you have read and agree to terms in our Privacy Policy * *

Signature Patient/Guardian

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Patient/Guardian Name

If guardian, relationship to patient

If other, please specify

Thank you for completing your registration form. We look forward to caring for you

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