Administrative - New patient registration form

New patient registration form

Last Name *

First Name *

Preferred name

DOB *

Ethnicitity

Country of Birth

Preferred Language:

Gender

Preferred pronouns final

She/HerHe/HimThey/Them

Residential Address *

Postal Address (if different)

Home Phone *

Work Number

Mobile Number

Email Address

Medicare Number

IRN Number (your position on MC Card)

Expiry

Pension

Pension Card

Pension

DVA Card

DVA Card Expiry

DVA Card Type

GoldWhite

If White - Conditions nominated on card

NOK Contact name *

NOK Contact number *

Relationship

Emergency Contact - must be different to above *

Emergency Contact number *

Relationship:

Occupation

Preventative screening - have you had any of the following?

Cervical ScreeningProstate Check (last 12 months)Breast Screen (last 2 years)Bowel Screen (last 2 years)

Please list dates if known

This form is double sided please flip and complete

Dates of screening

Have you had any vaccinations

TetanusInfluenza COVID-19 AZCOVID-19 PfizerPneumovaxShinglesHepatitis AHepatitis B

Please list dates if known

Dates of vaccinations

Do you ? *

Smoke YesNoDrink Alcohol YesNo

Frequency *

Do you have any of the following health conditions

DiabetesHypertensionHypotensionAsthmaOsteoporosisCancerChronic DiseaseCardiac conditionOther

Additional notes regarding your medical history

Do you have any allergies to medications or dressings? *

MedicationDressingsNone

Please indicate severity of allergic reaction ie: EPI Pen required

Details or allergies

Her Medical is committed to preventative care and conduct reminder systems for regular patients. Consent is assumed unless you prefer to “Opt Out” of this valued service. Please indicate your preference

SMS Reminders and Recall Reminder Systems *

SMS SMS OPT Out Reminder System - Preventative CareReminder System OPT Out Emails Emails OPT Out

Please indicate your consent to receiving all or either of the above

Knowing information about your identity and cultural background can help us provide healthcare that meets your individual needs. This form complies with the RACGP standards for General Practices. This means your information is kept private and secure, as required by federal and state laws. Your information is collected for administration purposes, including compliance with Medicare and health insurance Commission requirements.

Your signature *

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Todays Date *

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