New Patient Registration
Are you
*
Regular Patient
Visitor Only
Allied Health Patient Only
Full Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
/
Day
/
Month
Year
Date Picker Icon
Sex
*
Male
Female
Other
Cultural Background
*
Aboriginal
Torres Strait Island
Aboriginal Australian & Torres Strait Islander
Australian
Other
Residential Address
*
Street Address
Street Address Line 2
City
State
Postal Code
Postal Address (if different)
PO Box
Street Address Line 2
City
State
Postal Code
Phone Number
*
-
Area Code
Phone Number
Preferred Contact
*
Home
Mobile
Work
Email
Mail
Choose best method of contact
Medicare Number
*
Include REF number.
Medicare expiry date
*
MM/YYYY
DVA Number
if applicable
Pension Card Number
If applicable
Pension Concession Card expiry date
MM/YYYY
Health Care Concession Card
if applicable
Health Care Concession Card expiry date
MM/YYYY
Back
Next
Do you consent to
*
Rows
Yes
No
SMS Reminders
E Mail Correspondence
Your Health Summary being sent to My Health Record
Contact Details
*
Rows
Details
Home
Mobile
Work
Email
Emergency Contact Details
*
Rows
Name
Phone
Relationship
FIRST
SECOND
Your Occupation
*
Marital Status
*
Single
Married
Defacto
Separated
Divorced
Widowed
List any known allergies or sensitivities
*
Note reaction to each allergy. If no allergies put none. Put one allergy and reaction on each line
Alcohol Intake
*
Drinker
Non Drinker
Past Drinker
Days per week
Drinks per day
Year started
Year stopped
If Drinker or Past Drinker
Rows
Info
Days per week
Drinks per day
Year Started
Year Stopped
Tobacco Intake
*
Smoker
Non Smoker
Ex Smoker
If Smoker or Ex Smoker
Rows
Info
Days per week
Smokes per day
Year Started
Year Stopped
Significant Health Conditions
*
None
Diabetes
Asthma
Stroke
Heart Disease
Depression
Anxiety
Cancer
Other
Past operations
*
Please list on separate lines
Pap Smear (Cervical Screening)
Not applicable
Not Sure
Never
Other
Back
Next
Please review this information carefully and complete the questions on next page.
Back
Next
I have read the Bomaderry Creek Health information collection and use consent form on the previous page and understand the reasons why my information must be collected:
*
Yes
No
I am aware of my rights to access the information collected about me other than in situations where such access may be legitimately withheld.
*
Yes
No
I understand that I am not obligated to provide the information requested of me, however failure to do so may compromise the quality of Healthcare and / or Treatment given to me
*
Yes
No
I understand that if my information is to be used for any purpose, other than above, my further consent will be obtained.
*
Yes
No
I consent to the handling of my information by the Practice for the purpose set out above subject to any access or disclosure limitations I may notify the Practice of.
*
Yes
No
I am aware of the cancellation and non-attendance policy. That I must give at least 2 hours notice if cancelling an appointment. Should I not give such notice or I fail to attend a booked appointment a $20 missed appointment fee will apply.
*
Yes
No
Signature
*
Submit
Print Form
Should be Empty: