Online Patient Registration Form - Belmont Medical Practice

New Patient Registration Form
Patient Details
Name*

TitleFirst NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Date
Phone Number*
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email*
example@example.com
Country of Birth
Occupation
Do you identify as Aboriginal or Torres Strait Islander?

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have Medicare?*

YesNo
Medicare Number*
Medicare Reference*
Medicare Expiry Date
Under 16?*

YesNo
If under 16 years old please complete details for head of family on Medicare card*

TitleFirst NameMiddle NameLast NameDate of Birth
Medicare*

Medicare NumberMedicare Reference No.Medicare Expiry Date
Private Health Fund
Private Health Fund Number
Tick if Applicable

Concession/Pension/Health Care CardDept. of Veterans Affairs CardWorkers compensationInsurance claim
Emergency Contact Details

Family Member / A Friend / Room Mate / etc
Emergency Contact Name

TitleFirst NameMiddle NameLast Name
Contact Phone Number
Please enter a valid phone number.
Relationship to Patient
Concession/Pension/Health Care Details
Card Type
Card Number
Card Expiry Date
Dept. of Veteran Affair Details
Card Color
Card Number
Card Expiry Date
Workers Compensation Details
Employer Name
Employer Phone Number
Please enter a valid phone number.
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Claim Details
Insurers Name
Insurers Phone Number
Please enter a valid phone number.
Claim Number
How did you hear about us?*

OnlineWalk/Drive ByFamily/FriendsOther
By Completing This Form You Confirm
That all details provided are correct and I will inform the practice of any changes to my details. I authorise the practice to use my details to communicate with me and with other health professionals.

I am aware payment is required on the the day of consultation and extra fees may apply for certain requests. Fee schedule is available at reception.

I accept it is my responsibility to make follow/up appointments from any tests or referrals my doctor has asked me to undertake. This information will not be provided over the phone.

I understand that it is my responsibility to provide the doctor all past results or new results from other health providers.

I understand and agree with the Practice Policy form provided
Should be Empty:

New Patient Registration Form

Patient Details

Emergency Contact Details

Concession/Pension/Health Care Details

Dept. of Veteran Affair Details

Workers Compensation Details

Insurance Claim Details

By Completing This Form You Confirm