MHC NEW PT FORM

This information is private and confidential and is for use in your clinical file only. Please give us as much detail as possible to assist us in providing high quality care.

NEW PATIENT DETAILS: Please fill out relevant information.

Family Name*

First Name*

Middle Name

Preferred Name

Date of Birth*

Date

Ethnicity

Do you Identify as Aboriginal and/or Torres Strait Islander

Your Occupation

Address

Town

State

Post Code

Postal Address: If different to home

A/H Ph

Mobile*

Preferred contact Number

Email*

example@example.com

Medicare Number

Ref no (next to name)

Exp

DVA Number

DVA Card type

Pension/Healthcare/Commonwealth Senior Health Care card

Exp

Pension/Healthcare/Commonwealth Senior Health Care card

Next of Kin

Relationship

Phone

Emergency Contact Person

Relationship

Phone

Are you allergic to any medications? NIL KNOWN YES (If yes please specify):

YES (If yes please specify)

If yes, please circle level of reaction: Mild Moderate Severe Anaphylaxis Other:

SOCIAL HISTORY: Please circle the most appropriate answer and fill out all other areas

Alcohol Consumption: Do you Drink alcohol? No/Yes If yes, How many days per week

If yes, How many days per week

Smoking: Do you Smoke? Yes/No/Ex-Smoker If yes, how many per day?

yes, how many per day?

Year started?

Past Smoking History: Light Moderate Heavy

Year started?

Year stopped?

By becoming a patient of MyHealthCity Hope Island/ Pimpama and signing this New Patient form I agree and consent to the following: I will receive SMS from MyHealthCity to confirm my Appointments and Recall Reminders. I consent to the use / disclosure of my personal health information by the above named Practice to other health care providers involved directly or indirectly involved in my personal health care or medical treatment.

Acopy of our Practice Privacy Policy can be found in our Patient Information Booklet available from reception.

Patient Signature or Parent Guardian (If child is under 16 years of age)

Signature

Date

Printed Name

(How did you hear about us? Please circle) GOOGLE FACEBOOK HEALTHENGINE FLYER WORD OF MOUTH OTHER