Patient Registration "*" indicates required fields Name* Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Preferred name: D.O.B:* Mobile Ph:* Home Ph: Email:* Occupation: Address* Street Address Suburb Postcode REGULAR GP DETAILS(NB: ONLY if different to Referring Practitioner and you want them to receive a copy of your results) Name Dr.Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Clinic: PHYSIOTHERAPIST DETAILS(NB: ONLY if different to Referring Practitioner and you want them to receive a copy of your results) Name First Last Clinic MEDICARE & HEALTH INSURANCEMedicare No: Ref. No: Expiry: Pension No. Expiry: Veteran’s Affairs No: ARE YOU COVERED BY PRIVATE HEALTH INSURANCE? Yes No Fund Name:* Membership No:* Is this overseas cover?* Yes No ARE YOU CLAIMING THROUGH WORKCOVER OR TAC? Yes No Employer:* Phone:* Address* Street Address Suburb Postcode Claim Number:* Insurance Company:* Injury Date:* MEDICAL HISTORYCurrent Weight: Height (in CM): Do you take Aspirin or Cartia? Yes No Do you take any of the following medications? Warfarin Clexane Eliquis Xarelto I do not take any blood thinning medications: Have you ever had a bleeding or clotting problem? Yes No Do you have a Cardiologist? Yes No Cardiologist Name: Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Dr. First Last Cardiologist Phone: Cardiologist Email: Do you have any additional specialists managing your care? Yes No Specialist Name: Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Dr. First Last Specialist Phone: Specialist Email: CONSENTThis medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat, and be proactive in your health care needs. We will use the information you provide in the following ways: Administrative purposes in running our medical practice. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements. Disclosure to others involved in your health care, including treating doctors and specialists outside of this medical practice as advised by you. - I understand that this practice handles personal information in accordance with the National Privacy Principles enshrined in the Privacy Act 1988 (Commonwealth) - I consent to the handling of my information by this practice via email, fax, post and electronic mail for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice. - I acknowledge that email is not a secure for of transmission, however I understand that this practice will take reasonable steps to protect this information and my privacy when transmitting information. Name* First Last Signature*Date* MM slash DD slash YYYY Is the patient is a minor, unable to sign, or you are their legal guardian? Yes No Yes - please complete the following:Name First Last SignatureDate MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
