• Image field 94
  • CSMC Patient Registration

  • Patient Registration Form

  • Collins Street Medical Centre are committed to providing our patients with the best care. To do this it is essential that your health record is kept up to date and accurate.

    ALL patients are asked to complete the following.

  • SECTION 1 : ALL PATIENTS

  • Booked Appointment Time:
     - - :
  • Format: (00) 0000-0000.
  • Format: (00) 0000-0000.
  • Marital Status (Optional)

  • Sexuality (Optional)

  • Cultural Background

    Australia is a genuinely multicultural society. To tailor appropriate care, encourage understanding and appreciation between people from different nationalities and backgrounds, it is important that we have some basic information around your cultural background.

  • To assist with health initiatives are you: -
  • Do you have any allergies or are you sensitive to any drugs or dressings?*
  • Smoking*
  • Alcohol
  • Are you an Interstate or Overseas visitor to Melbourne?
  • Do you intend to use the practice for ongoing medical care?*

  • SECTION 2 : ALL PATIENTS

  • Your Health and Lifestyle History:

  • How often do you engage in physical activity

  • If 50 or older, have you had a test as part of the National Bowel Cancer Screening Program?

  • Your Medical History

  • Do you have a history of: -

  • Asthma
  • Hypertension
  • Diabetes
  • Chronic Illness

  • Your Family History

  • Diabetes
  • Bowel Problems
  • Heart Disease
  • Kidney Disease
  • Depression
  • High Cholesterol
  • Cancer
  • Asthma/Respiratory Problems
  • Other

  • Your Immunisations

  • An up to date record of your current immunisation status is valuable medical information. 

    This would include - Flu, Gardasil, Hepatitis A, Hepatitis B, Chicken Pox, Meales, Pneumococcal, Polio, Tetanus, Meningococcal

    Prior to attending for your appointment, please check if you have this information and it would be appreciated if you could bring documentation with you and/or discuss with the practice nurse.

  • If completing this form for a child, are their immunisations up to date?

  • SECTION 3: ALL PATIENTS PRIVACY, YOUR CONSENT & PREVENTATIVE HEALTH

    (Recall and Reminder Systems) ALL PATIENTS TO COMPLETE THIS SECTION

  • The practice routinely sends SMS appointment reminders to patients.

  • Consent for SMS reminders*
  • The practice adopts a proactive approach to assist in the management of your health and well being. We will communicate with you around various health related topics including preventive care, follow up health information and early case detection reminders and recalls; we utilise a variety of communication methods including post, telephone, secure email or SMS. (We will not send “junk mail”.)
  • Consent for Preventative Health Communication*
  • The practice may participate in research and quality assurance activities to improve individual and community health care and practice management.  Usually information that does not identify you is used but should information that will identify you be required you will be informed and given the opportunity to “opt out” of any involvement.
  • Consent for Participation in sharing of de-identified information*

  • You may opt out of any of the above at any time in the future by advising our reception staff.

    The practice respects your privacy and adheres to the  Privacy Act 1988  and the Australian Privacy Principles 2014

  • Is there any other information that you feel may be relevant to your healthcare -

  • This practice prides itself on quality and innovative health care. As part of our commitment to providing optimal care, all new patients are seen by one of our practice nurses prior to the first consult with a GP. 

    I agree that this information is accurate and true to the best of my understanding and that there is no other information that I believe the practice should know that may affect / or have an influence on the medical treatment / advice I will be provided with?

     

  • Reload

  • Keep a copy of your data by printing this form before submitting.

  •  

  • Colllins Street Medical Centre
    7th Floor/ 267 Collins Street
    Melbourne VIC 3000 

    Tel: (03) 9654 6088

  • Should be Empty: