Patient Registration Form

PATIENT DETAILS

Title --Select-- Mr Mrs Ms Miss Master Dr Other

Family Name*

First Name*

Middle Name(s)

Full Name of Parent, in the case of minors

Street Address*

Suburb*

State --Select-- NSW QLD SA TAS VIC WA ACT

Postcode*

Email*

Mobile*

Telephone

Work Phone

Sex

Age

Date of Birth*

Occupation

NEXT OF KIN

Name

Relationship

Mobile

Telephone

Fax

HEALTH INSURANCE

Private Health Insurance*

• Yes
• No

Health Fund Name

HF Number

Aged Care Pensioner

• Yes
• No

Pension Number

Expiry Date

Medicare Number

Position on Card

Veterans Affairs Care No

Is this a Workers Compensation Claim?

• Yes
• No

REFERRING DOCTOR

Referring Dr's Name

Referring Dr's Address

Suburb

State

Postcode

General Practitioner’s Name

General Practitioner’s Address

Suburb

State

Postcode

General Practitioner’s Telephone

MEDICAL HISTORY

Past History

• High blood pressure
• Lung disease
• High cholesterol
• Diabetes

Smoking History

• Yes
• No
• Exsmoker

How many per day if still smoking

Allergies

• Yes
• No

Allergies

Previous Surgery

Family history of bleeding or anaesthetic complications

Medications

High risk group? (please select all that may apply)

• Hepatitis C
• HIV
• CJD

CONSENT FORM

Please read the consent form carefully and sign where indicated.

The above personal and medical information is solely for the purpose of providing you with the best quality of healthcare. This information will also be used for administrative and billing purposes and for referrals across other specialists and for medical tests.

I understand that this practice has a privacy policy for handling patient information and I am also aware of my right to access this information gathered about me, except in certain circumstances where the information is withheld legitimately.

I consent to this practice handling my information for the aforementioned purposes.

Patient nameParent/Guardian if under 18 years

SignedParent/Guardian if under 18 years

Date

Releasing your information to next of kin

Please specify if you give consent to releasing details of treatment to your nominated next of kin.

• Yes
• No