New Patient Registration – Medical & Dental Mornington VIC

Patient Details

Title

Surname

Given Name/s

Date of Birth

Gender

Marital Status

Medicare No.

Ref No.

Expiration Date

Pension, Health Care Card or DVA White/Gold Card No:

Expiration Date

Occupation

Employer

Home Address

Postcode

Postal Address

Postcode

Phone (Mobile)

Phone (Home)

Phone (Work)

Next of Kin

Name

Relationship to you

Phone (Mobile)

Phone (Home)

Phone (Work)

Emergency Contact

Name

Relationship to you

Phone (Mobile)

Phone (Home)

Phone (Work)

Do you identify as someone from a culturally and/or linguistic diverse background?

Yes No

If yes, Please indicate ethnicity

To assist with health initiatives - are you Aboriginal or Torres Strait Islander?

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

Health Questionnaire

Allergy to medication or food?

Yes No Unknown

Smoker Status

Never Smoked Ex-Smoker Smoker

Alcohol Intake

Nil Yes

Recreational Drugs

Yes No

Regular Medications

Nil Yes

Current/Previous Medical Conditions

Nil Yes

Family Medical History

Nil Yes

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 and uploaded to My eHealth Record as a part of the quality improvement activities in this practice.

Yes No

I give permission for my personal information to be collected, used and disclosed as described in this practice policy. I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.

Yes No

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 smears and other health reviews.

Yes No

I consent to being contacted with reminders by sms/phone/email.

Yes No