Please fill this form to request an appointment Contact Information Title: MissMsMrsMrMasterDoctor Gender: MaleFemaleNon-binaryGender DiverseTransgenderDifferent Identity Given Names: (required) SURNAME: (required) Date of Birth: (required) Postal Address: (required) Suburb/Town: (required) Post Code: (required) Telephone Home: Mobile No: (required) Email Address: (required) Cultural Identity Do you identify as being Aboriginal? YesNo Torres Strait Islander? YesNo Occupation Country of Birth Ethnicity (required) Australian non indigenousAboriginal but not Torres Strait IslanderTorres Strait Islander but not AboriginalBoth Aboriginal and Torres Strait Islander Medicare Medicare Card No: (required) Medicare Card Reference No: (required) Medicare Card Expiry Date (required) Pension/DVA/Private Health Fund/Health Care Card No: (If Applicable) Type of Pension/DVA/Private Health Fund/Health Card: Pension/DVA/Private Health Fund/Health Care Card Expiry Date Next of Kin/ Emergency Contact Name: (required) Relationship to Patient: (required) Phone No: (required) Address: (required) Allergies and medicines List allergies and intolerances to medications (required) List Regular medications and doses, and complementary medicines and doses Family and Social History Any significant family history -mother -- Any significant family history -father -- Martial Status Smoking History -per day Standard Alcoholic drink per day Women only Have you ever had a Cervical screening: YesNoNot sure Men only Have you ever had a prostate check: YesNoNot sure 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 Tap to sign here ↓ (required) Clear
