Patient Registration Form

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
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? *

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.
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