New patient registration Title*Please SpecifyMrMrsMsMissMasterMxName* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Ethnicity* Select the most applicable:*Please SpecifyAboriginalTorres Strait IslanderBothNeitherBirth Sex*MaleFemaleGender Identity*MaleFemaleGender DiverseNon-BinaryOtherContact DetailsAddress* Street Address Unit/Apt./Suite/Building Number Suburb State Postcode Mobile* Home Work Occupation Email Emergency Contact DetailsNominated Person Name* Relationship* Contact Number* Next of Kin Name Relationship Contact Number Medicare DetailsCard Number* IRN* Individual Reference NumberExpiry Date* Do you hold any of the following concession cards? Pensioner Card Health Care Card Veterans Affairs Card No Pensioner Card DetailsCard Number* Expiry Date* Health Care Card DetailsCard Number* Expiry Date* Veterans Affairs Card DetailsCard Number* Expiry Date* Your Medical HistoryAny information you can provide will assist our doctors to provide optimum care for you and your family. If you prefer to provide this information directly to the doctor, please advise the reception staff. All staff are bound by confidentiality agreements to maintain your privacy.Height Weight (kg)Are you allergic or sensitive to any medications?*Please list any allergies or sensitivities.Do you suffer from any of these medical conditions? Asthma Diabetes Hypertension Heart Disease Mental Illness When did you last have a Pap Smear?*When did you last have a Pap Smear?* Pap Smear Applicability This does not apply to me Do you smoke?* No Yes Have you smoked previously?* No Yes How frequently do you smoke?* How many per day/week?When did you give up smoking?* Do you drink alcohol?* No Yes How often do you drink?* Family Medical HistoryHave any of your family members experienced any of the following? Diabetes Hypertension Asthma Cancer Mental Illness Heart Disease Other Privacy Agreement & Patient Consent* I consent to the practice privacy agreementYour medical record is a confidential document. It is the policy of this practice to maintain security of personal health information at all times to ensure that this information is only available to authorised members of staff. We abide by the National Privacy Principles available at the OIAC website. Our practice provides our patients with quality improvement activities and clinical audits, preventative care and early case detection reminders e.g..: immunisations, annual health checks, skin checks and you agree to be part of a recall system.Electronic Signature*Signature Date: 21/11/2024CommentsThis field is for validation purposes and should be left unchanged.
