We need this information to provide the best quality care. Your personal health information is kept private and secure, as required by federal and state privacy laws. If you have concerns, please leave blank and discuss with your GP. This form complies with the Royal Australian College of General Practitioners Standards for general practice.

 

Title:
Surname*:
Given Names*:
DOB*:
Country of Birth*:
Gender*: MaleFemale
Are you of Aboriginal/Torres Strait Islander Origin?* YesNo
Address*:
Home Phone:
Work Phone:
Mobile Number*:
E-Mail:
Occupation:
Next of KIN:
Emergency Contact*:
Phone*:
Medicare Details:
Expiry Date:
REF:
Significant Family/Social History:
Allergies:
PATIENT CONSENT: Our practice undertakes research, professional development, and quality assurance/improvement activities to improve patient
care. All people accessing personal health information for this purpose have signed a written confidentiality agreement.
I consent to my health record being reviewed as part of the quality improvement activities at this practice.* YesNo
Our practice uses a reminder system to improve the quality of your health care. The practice sends reminders by mail or telephone for procedures such as
vaccinations, Pap tests and other health reviews.
I consent to being contacted with reminders as part of the quality improvement activities at this practice.* YesNo
TRANSFER OF HEALTH INFORMATION: You may have consistently consulted with a GP at another practice. The health information held by that GP may assist us
with your future health care needs. You may wish to have a copy or a summary of your health records transferred to this practice. Please ask the receptionist for information about how this can take place.

 

 

Please note: Email is for administration purposes only. Email communication for medical advice and information is prohibited and will NOT result in a response from our clinical team. Please call or visit our clinic for all medical information.