Patient Registration

Please see the following options to access pdf versions of our Patient registration form. Please print out, complete and bring along to your appointment. Alternatively fill out the online form below, or simply arrive 5 minutes early to your appointment and fill out in the rooms.

PDF New patient information form

Word Doc New patient information form

Name*
Prefix First Last
Preferred name
Address
Street Address City State Post Code
Home Ph
Work Ph
Mobile Ph*
Consent to contact via SMS?
- Yes
- No
Email*
Date of Birth
Occupation
Medicare No
Reference on card
Expiry
Health Fund
Membership Number
DVA Card Number
Type
Pension card number
Expiry Date
Referring Dr
Specialist or GP?
Usual GP (if different from above)
GP address
GP phone
GP Fax
Guardian details
(if patient is 17 years and under)
Name
First Last
Contact number:
Medicare No
Reference on card
Date of birth
Emergency contact details
Emergency contact name:
Relationship to patient:
Number:
Medical Information
Additional Files - Xray/CT/MRI/Ultrasound
Drop files here or

Accepted file types: jpg, gif, png, pdf, jpeg, doc, docx, Max. file size: 8 MB, Max. files: 4.
Medical conditions
Medications
Allergies
Social & Lifestyle History
Do you smoke?
- Yes
- No
Number of cigarettes/ packs per day:
Past Smoking History:
- Ex Smoker
- Light
- Moderate
- Heavy
Year started smoking:
Year stopped smoking:
Do you drink alcohol?
- Yes
- No
Days per week:
And/or Standard drinks per day:
Worker's compensation / Motor Accident claims / Other:
Is this a worker's compensation / Motor accident claim?
- yes
- no
Employer's Name
Employer's address
Employer's Ph
Employer's Fax
Date of Injury
Insurance Co./Solicitor
Phone
Fax
Claim number
Patient Health History
General Health
- Recent weight change
- Loss of appetite
- Fatigue
- Fever/chills
Family History
Have any members of your family had:
- Deep vein thrombosis (DVT)
- Diabetes
- Asthma
- Heart disease
- Cancer
- Other
Other family history issue:
Allergies
- Drug allergy
- Food allergy
- None
- Other (please specify below):
Other Allergy
Ears, Nose, Mouth, Throat
- Difficult swallowing
- Earaches
- Loss of hearing/deafness
- Loss of smell
- Loss of taste
- Pain when chewing
- Ringing in ear
- Sinus infection
- Sore in mouth
- None
Heart and Lungs
- Pain in chest
- High blood pressure
- High cholesterol
- Irregular heart beat
- None
- Other (please detail below)
Other Heart and Lung issue:
Muscle/Joints/Bones
- Back pain
- Difficulty walking
- Neck Pain
- None
Joint Pain - Specify location:
Joint stiffness or swelling - Specify location:
Muscle pain or tenderness - Specify location:
Neurological
- Back Balance trouble
- Black outs/loss of consciousness
- Difficulty speaking
- Difficulty walking
- Facial drooping
- Headaches
- Injury to the brain or spine
- Light headed or dizziness
- Memory loss
- Mental confusion
- Migraines
- Mini stoke
- Neuropathy
- Numbness or tingling
- Mini stoke
- Paralysis
- Stroke
- Tremors
- Weakness
- None
- Other
Other Neurological issue:
Are you?
Are you?
- Left handed
- Right handed
- Both
Psychiatric
- Depression
- Anxiety
- Eating disorder
- None
- Other
Other psychiatric issue:
Pulmonary
- Asthma
- Blood in cough
- Cancer
- Chronic or frequent cough
- Emphysema
- Pneumonia
- Shortness of breath
- None
- Other
Other pulmonary issue:
Skin
- Rash or itching
- Sun sensitivity
- Hair loss
- Colour changes
- None
- Other
Other skin issue
Privacy
Privacy consent*
- Yes
- No
I have read the Privacy Act Consent information regarding the handling of my information by this Practice for the purposes set out by the Form. I consent to the handling of that information subject to any limitations on access or disclosure of which I may notify this practice.
PRIVACY ACT CONSENT INFORMATION
Current as of 20.9.18
Please carefully read the following information about privacy issues then sign this form where indicated below. It will be stored in your file and you may examine it or change it at any time.

The law gives you certain privacy rights regarding the information that you provide to this medical practice. We require your consent to collect personal information about you. Your attendance at this and subsequent appointments implies that you consent to us knowing about your health situation either for a particular event or generally. This form explains your rights regarding our use of the collected information, and how we may disclose it to other medical service providers. The information we may ask you to give us is personal. However by refusing to provide such information restricts our ability to provide you with the standard medical care that you expect.

The main reason we collect information from you is to can assess, diagnose and treat your illnesses properly and be pro- active in your health care. We will also use the information you provide in the following ways:
- Administrative of this medical practice.
- Billing, including compliance with Medicare and Health Insurance Commission requirements.
- Disclosure to others involved in your health care, including treating doctors, specialists, physiotherapists outside this medical practice who are, or may become involved in treating you. This may occur through referral to other doctors, for medical tests and in the reports or results returned to us following the referrals.
- Disclosure to others for medical defence purposes if necessary.
- Disclosure to other doctors in the practice, locums and Registrars attached to the practice for the accessed for the purpose of patient care and teaching. Please let us know if you do not want your records accessed for these purposes and we will note your record accordingly.
- Disclosure for research and quality assurance activities to improve individual and community health care and practice management. You will be informed when such activities are being conducted and given the opportunity to ‘opt out’ of any involvement.
- Disclosure to insurer, employer or solicitor where applicable.
I have read this form and understand why collecting of information about me is necessary. I am also aware that this practice has a privacy policy on handling patient information.

I understand that I am not obliged to provide any information requested of me. I also understand that failure to provide this medical practice with all the information it needs may restrict the practice’s ability to provide the quality of the health care and treatment that I want.

I am aware that I have the right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.

I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.

I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure about which I notify this practice now or at any future time.

I acknowledge that I have read this form before signing it and that a member of staff of this practice has at my request, clarified any aspects of it that I did not at first understand.

I understand that I can request for a copy of this Privacy Act and Consent Information.
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Patient Registration

Guardian details

Emergency contact details

Medical Information

Social & Lifestyle History

Worker's compensation / Motor Accident claims / Other:

Patient Health History

Privacy

PRIVACY ACT CONSENT INFORMATION