Online Registration Form

Your privacy

The information you provide here is collected for the purpose of registering you as a patient of the practice and is handled in line with our privacy policy. Fields marked * are required.

Medicare

Please copy the details exactly as printed on your card.

Medicare Card No

Medicare Card Reference No

The single digit beside your name.

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 the following?

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderLGBTQ+

Next of Kin / Emergency Contact

Name

Relationship to Patient

Phone No

Address

Emergency Contact If different from next of kin

Name

Relationship to Patient

Phone No

Address

Smoking and Alcohol History

Men Only

Have you ever had

A Prostate Check? Yes NoDate of last checkWas it Normal Abnormal

Privacy, Consent & Signature

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.

Please indicate your preferences (tick to consent, leave blank to decline):

I consent to receive SMS messages regarding future appointmentsI consent to messages being left on my telephone message serviceI consent to registering with MyMedicare with HSMI consent to the potential use of transcription software during my medical appointment, for the purpose of accurate documentation and maintenance of my medical records

Tap to sign here *

By signing above and pressing Submit you declare the information provided is true and correct to the best of your knowledge.

Registration received

Thank you — we've received your registration. Your reference number is . Please call (03) 5454 3973 to book your first appointment, and remember to bring your Medicare card.

Registration received

Prefer paper?