New Patient Registration Section A: Personal DetailsName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last D.O.B. DD slash MM slash YYYY Date of BirthGenderFemaleMaleTransgenderNon-binaryPrefer not to respondGenderMarital StatusSingleMarriedDefactoSeparatedDivorcedWidowedMarital StatusAddress Street Address Suburb State Postcode Patient Contact(Required)PhoneEmail EmailOccupationOccupationMedicareMedicare NumberMedicare NumberMedicare Individual Reference NumberMedicare Individual Reference NumberMedicare Expiry mm/yyMedicare Expiry (mm/yy)Department of Veteran AffairsDo you have a DVA cardDo you have a DVA card Yes No DVA NumberDVA NumberDVA Card ColourGoldWhiteLilacOrangeDVA Card ColourDVA card conditionsDVA card conditionsHealth FundFund NameFund NameMember NumberMember NumberReference NumberReference NumberReferring Doctor DetailsReferring Doctor NameReferring DoctorPractice addressPractice addressIs your referring Doctor different to your regular GP?Is your referring Doctor different to your regular GP? Yes No Regular GP NameRegular GP NameRegular GP Practice AddressRegular GP Practice AddressNext of KinNOK NameNOK NameNOK RelationshipSpouseDefacto partnerChildFamily memberNOK RelationshipNOK Contact NumberNOK Contact NumberEmergency Contact(if possible not the same as NOK)Emergency Contact NameEmergency Contact NameEmergency Contact RelationshipClose friendNeighbourFamily memberEmergency Contact RelationshipEmergency Contact NumberEmergency Contact NumberSection B: For Patients under 16This information is required for processing Medicare claims; Medicare will not accept claims for minors.Is the patient under 16Is the patient under 16? Yes No Parent or Guardian NameParent or Guardian NameGuardian D.O.B. DD slash MM slash YYYY Guardian Date of BirthGuardian Medicare NumberMedicare NumberGuardian Medicare Individual Reference NumberMedicare Individual Reference NumberGuardian Medicare Expiry mm/yyMedicare Expiry (mm/yy)Section C: Medical HistoryMedical ConditionsPlease list your medical conditionsMedicationsPlease list the medications you takeOperationsPlease list your previous operationsSupplementsPlease list any non-prescription supplements you take eg fish oil, chondroitin, tumeric, mushrooms etcAre you allergic to any medications?Are you allergic to any medications? Yes No AllergiesList of allergiesHave you ever had a blood clot in your legs or in your lungs?Have you ever had a blood clot in your legs or in your lungs? Yes No Do you smoke or vape?Do you smoke or vape? Yes No Smoking or vaping detailsSmoking or vaping detailsDo you drink alcohol?Do you drink alcohol? Yes No Drinking detailsHow much and how often do you drink?Section D: Important Practice InformationSMS ConsentDo you consent to receiving SMS and emails for appointments, radiology / pathology reminders? Yes No Telehealth ConsentDo you consent to participating in telehealth consultations (video or phone calls)? (Additional paperwork will be sent to you prior to your telehealth consultation) Yes No Following your appointment with Dr Ward, you will receive an account, which must be paid on the day of consultation. Payments can be made by cash, eftpos, credit card or direct deposit. We direct bill all Department of Veteran Affairs Gold Card holders. Accounts for active Defence Members will be invoiced directly to Defence. Certain medical examinations – such as medicals, legal reports & commercial driver’s licenses are not claimable from Medicare. If you require any further information regarding cost of these please ask reception staff. Full Payment is required on day for WorkCover claims that do not currently have a claim number. You are then able to follow this up with your claim agent. Privacy: Amendments to the Privacy Act came into effect in December 2001. As a provider of healthcare services it is important that you are aware ‘ of how any personal information collected by this practice is used. The personal information collected is that deemed necessary to best attend to, and treat the presenting health condition(s). Personal information is primarily used within the practice, but sometimes it is used to ensure quality and continuity of health care for you and must be partially or fully disclosed to others outside of the organisation, depending on the circumstances. e.g. when referring to another specialist medical practitioner or when requesting blood tests, urine tests, x-rays etc; when itemising accounts for Medicare. Freedom of information: All patient files that include personal information, test results etc. are the property of this practice. However, should you choose to visit another Doctor at any time, copies of the appropriate files can be forwarded on receipt of your written request. Under no circumstance will this practice divulge personal information without your prior written consent.Consent I have read & understand all information provided above regarding fees, privacy & freedom of information. I also am aware that at the conclusion of all consultations there will be a request for full payment of the account.PhoneThis field is for validation purposes and should be left unchanged.
