Patient Registration Form

Patient Registration Form
Name*

First NameLast Name
Preferred Name
If different to above
Date of Birth*

DayMonthYear
Date
Residential Address*

Address 1

Address 2

SuburbState

PostcodeCountry
Phone*
Email*
Next of Kin

Please include these details for emergency contact
Name of Next of Kin*

First NameLast Name
Relationship*
Contact Number for Next of Kin*
Medicare Details
Do you have a Medicare Card?*

YesNo
Medicare Number
10-Digit Number
Reference Number
On left of your name
Expiry Date
Do you have a DVA Card?*

YesNo
DVA Card Number
DVA Card Type

GoldWhite
GP Details
Is your regular GP the doctor that referred you?*

YesNo
Name of your GP

First NameLast Name
Address

Address 1

Address 2

SuburbState

PostcodeCountry
Private Health Insurance
Do you have Private Health Insurance Hospital Cover*

YesNo
Name of Health Fund
Membership Number
Unique Patient Identifier (UPI)
Parent/Guardian Information

(For children under 16 years old only)
Parent's Name

First NameLast Name
Parent's Date of Birth

DayMonthYear
Parent's Medicare Reference Number
Parenting Orders - Are there any Parenting Orders our Clinic should be aware of?

YesNo
Health Background
Health Summary - Please mark any relevant items

DiabetesHeart AttackStrokeThyroid ProblemsHepatitis/HIVKidney DiseaseLiver DiseaseHigh Blood PressureReflux DiseaseBleeding/Clotting DisorderAsthma/Lung DiseaseEpilepsyCancerAlcoholSmoking
Allergies | Do you have any known allergies to medications or food?*

YesNo
Please specify details
Major Operations | Have you had any previous major operations, not listed on your referral?*

YesNo
Please specify details
Medications | Do you take any medications not listed on your referral?*

YesNo
Please specify details
Privacy Information - (Privacy Act 1988 (Cth) and HRIP Act 2002 (NSW))

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 assist, diagnose and treat illnesses and be pro-active in your health care. We will also use the information you provide in the following ways:
- Administrative purposes in running our medical practice
- Billing purposes, including compliance with Medicare and HIC requirements
- Disclosure to other doctors and specialists outside of this medical practice
- Disclosure to other doctors within the practice
- Disclosure for research and quality assurance activities
I have read the information above and understand the reasons why my information must be collected. 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 am also aware that this practice has a privacy policy which contains information about accessing and seeking correction of personal information and privacy complaints handling process. I am aware of my right to access the information collected about me, except in circumstances where access might be legitimately withheld with an explanation provided. I understand that if I request access to information about me, the practice will be entitled to charge fees to cover time and administrative costs.
Email

Email will NOT be used for marketing purposes. It may be used to communicate with you, paying regard to your privacy and confidentiality. However, email is NOT encrypted and therefore carries some risk. Email does not replace other forms of communication, such as consultation visits. Email is only used to communicate non-urgent matters, as it isn’t checked daily. Please indicate if you consent below.
I CONSENT to email communication with and from this practice:*

YesNo
Clinical Photography

Clinical photography, generally of inside your ear, nose or throat, is used in this practice to document your clinical progress and is an important part of your treatment. Within the practice, the images are securely stored on password protected and encrypted media and linked to your file. Occasionally images are used for research, teaching or education purposes, and if so, will be completely de-identified and unlinked from your file to protect your privacy. Please indicate if you consent below
I CONSENT to collection and use of medical imaging or clinical photos for teaching or education:*

YesNo
Please choose how you would like to send your referral?*

Upload FileReferral to be faxed/emailed
Click to Upload File

Cancelof
Signature*

Clear
In accordance with State and Federal Privacy Legislation, I hereby consent to my information being collected and released, if necessary, to assist in my continuing care and treatment. By clicking the SUBMIT button below, I agree to this and electronically sign. If under 16 years of age, this form must be completed by a parent/guardian.
Should be Empty:

Patient Registration Form

Next of Kin

Medicare Details

GP Details

Private Health Insurance

Parent/Guardian Information

Health Background