Online Registration Form | Hargreaves Street Medical Practice

Please fill this form to request an appointment

Contact Information

Given Names: (required)

Preferred Name: (required)

SURNAME: (required)

Date of Birth: (required)

Residential Address:

Suburb/Town:

Postal Address:

Suburb/Town:

Telephone Home:

Mobile No:

Telephone Work:

Email Address: (required)

Medicare

Medicare Card No:

Medicare Card Reference No:

Medicare Card Expiry Date

Pension/Health Care Card No:

Type of Pension/Health Card: PensionerHealth Care Card

Pension/Health Care Card Expiry Date

Type of DVA Card: GoldWhite

DVA Card No:

DVA Card Expiry Date

*IF THE NEW PATIENT IS A CHILD UNDER 16 PLEASE PROVIDE:

PARENTS NAME:

Parents Date of Birth

Parents Medicare Number

Cultural Identity

Occupation

EMPLOYER:

Country of Birth

IF NOT AUSTRALIA, WHAT YEAR DID YOU ARRIVE:

Ethnicity

Language Spoken Other Than English

Do you identify as being any of following? AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderLGBTQ+

Next of Kin/ Emergency Contact

Name:

Relationship to Patient:

Phone No:

Address:

Emergency Contact

Name:

Relationship to Patient:

Phone No:

Address:

Allergies and medicines

Any other medical conditions/past surgeries:

Allergies/ Adverse Reactions:

Current Medications:

Family and Social History

Smoking and Alcoholic History

Smoker Never SmokedEx-SmokerSmoker

If Ex-Smoker, Year Quit:

If Smoker, Number/Day:

Alcohol NeverMonthly or less2-4 Times per month2-4 Times per week4+ Times per week

How many standard drinks would you consume each time you drink:

Preventative Health / 45-49 Health Assessment

Women only

Have you ever had

A Cervical Screening? YesNo Date: Was it: NormalAbnormal

A Breast Screen? YesNo Date: Was it: NormalAbnormal

Men only

Have you ever had

Prostate Check? YesNo Date of last check: Was it: NormalAbnormal

IF YOU ARE OVER 65 YEARS OLD:

How Did You Hear About Us?

This 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 a full medical history so that we may properly assess, diagnose, treat and be pro-active in your health care needs. We may 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 this practice. This may occur through referral to other doctors, or for medical tests and in the reports returned to us following the referrals. • Disclosure to other doctors, allied health workers and nurses who may work in the practice, including Locums and Accreditation Surveyors, for the purpose of patient care, teaching and accreditation. • Disclosures for research and quality assurance activities to improve individual and community health care and practice management. This information will be de-identified.

By signing this document below, I agree to the following: • I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information. • I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me. • I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances. • By completing the section below and providing a signature, I consent to the handling of my information by this practice for the purposes set out above, subject to any limitation on access of disclosure that I notify the practice of. • I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained. • I consent or decline as indicated to receive an SMS message regarding future appointments • I consent or decline as indicated to messages being left on telephone message service • I consent to register with my-medicare with HSM • Do you consent to the potential use of transcription software during your medical appointment for the purpose of accurate documentation and maintenance of your medical records

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