New Patient Form

PATIENT REGISTRATION, HEALTH INFORMATION AND CONSENT FORM

 Mr  Mast  Mrs  Miss Ms





 Y N





 Yes - Aboriginal Yes - Torres Strait Islander Yes - Aboriginal & Torres Strait Inslander
 Yes No











Patient Consent-

( please provide your consent for your preferred method of contact:  Phone SMS Post)

To enable ongoing care and total quality improvement within this practice, and in keeping with the Australian Privacy Principles (2014), we wish to provide you with sufficient information on how your personal health information may be used or disclosed. By signing below, you (as a patient/guardian) are consenting that on obtaining your personal health information it may be used or disclosed by the practice for the following purposes:

  • Follow up reminder/recall notices for treatment and preventative health care
  • For accounting procedures and the collection of professional fees
  • The diagnosis
    and treatment of my condition, including the communication of relevant
    information only, to
    practice staff, specialists and other health care providers to ensure quality
    care is provided.
  • For legal related disclosures required by the court of law
  • For disease notification as required by law
  • For use when seeking treatment by other doctors in this practice
  • For the purpose of obtaining medical records, previous clinical reports and management regimes,
    etc. from other medical practitioners, institutions, laboratories etc.
  • To inform the next of kin identified in my patient information of the outcome of treatment or to
    obtain consent to necessary treatment when I am not able to provide such consent



Health Information





 No

 Yes No

 Asthma Diabetes Mental Health Concerns Cancer Heart Disease

IT IS IMPORTANT FOR YOUR ONGOING HEALTH TO COMPLETE THE FOLLOWING QUESTIONS



 No Significant Family History
 Yes No
 Yes No

 Diabetes Hypertension Heart Disease Stroke Colon Cancer Breast Cancer Depression
 Diabetes Hypertension Heart Disease Stroke Colon Cancer Depression Operations

 Yes No

 No Yes
 Non Drinker

 Non Smoker Ex-Smoker Smoker

 Do not use drugs


 not sure never
 not sure never

 not sure never
 not sure never
 not sure never

PLEASE RETURN PAGE 1 TO RECEPTION AND HAND PAGE 2 TO YOUR DOCTOR