Patient Registration Form
Name (as appears on Medicare Card)
*
Title
First Name
Last Name
Preferred name
(optional)
Pronouns
ex: he/him, she/they
Date of Birth
*
-
Day
-
Month
Year
Parent's Name (if under 18)
Title
First Name
Last Name
Parent's Name (if under 18)
First Name
Last Name
Parent's Date of Birth (if under 18)
-
Day
-
Month
Year
Parent's Medicare Number (if under 18)
ex: 1234 56789 0 (1)
Parent's Medicare Patient Number (in front of name)
ex: 1
Address
*
Street Address
Street Address Line 2
Suburb
State / Territory
Post Code
Postal Address (if different from residential address)
Telephone
*
Primary No.
Home Phone
Alt Phone
Email
example@example.com
Medicare Number
ex: 1234 56789 0 (1) or N/A
Medicare Patient Number (in front of name)
ex: 1
Medicare Expiry
MM/YYYY
Pension Card Number (blue card)
ex: 123-456-789A
Pension Card Expiry
DD/MM/YYYY
Veteran's Affairs Number
ex: AB 123456C
(select if applicable)
Gold Card
White Card
Veteran's Affairs Card type
Is your problem related to a TAC Claim?
*
Yes (if yes, please provide a copy of the TAC claim paperwork)
No
Date accident occurred (TAC)
-
Day
-
Month
Year
Date
Date your claim was approved by TAC
-
Day
-
Month
Year
Date
TAC Claim Number
ex: 01/23456
Do you have Health Insurance? (Hospital cover only)
*
Yes
No
Health Insurance Fund Name
*
Health Insurance Membership No.
*
Health Insurance Level of Cover
ex: Top Hospital, Extras Only, etc.
Date Joined
Next of Kin
Name
Relationship
Address
Contact No.
Name of your Local Doctor
Title (eg. Dr)
First Name
Last Name
Local Doctor's Address
Medical Practice Name
Street Address
Suburb
State / Territory
Post code
List of Current Medications
*
(N/A if none)
Allergies
*
(N/A if none)
Are you up to date with your COVID-19 Vaccinations?
*
Yes
No
Do you plan to be up to date with your COVID-19 Vaccinations?
*
Yes
No
Have you been overseas in the last 14 days?
Yes
No
Are you showing any symptoms of COVID-19? (Fever, cough, sore throat, shortness of breath, etc)
Yes
No
Are you currently awaiting test results for COVID-19?
Yes
No
Have you been in close contact with anyone who has been overseas, shown symptoms, or is awaiting test results/tested positive for COVID-19?
Yes
No
COVID-19 Risk Assessment Declaration.
I understand that if any of the above conditions change, I will notify Dr Charles Su's offices immediately, at 9650 0278, or by email at staff@drcharlessu.com.au
COVID-19 Vaccination Declaration.
I understand that I and any accompanying persons will need to provide proof of vaccination for COVID-19 (showing that I have been fully vaccinated for at least 14 days) upon arrival. If unable to do so, I acknowledge that I may not be able to be seen by Dr Charles Su in person.
Submit
Should be Empty: