New Patient Form MrMrsMissMs Surname (required) Firstname/s (required) Date of Birth (dd/mm/yy) Country of Birth: Sex: MaleFemale Ethnic/cultural background (required): Medicare Medicare No: Line No: Expiry Date (mm/yy) Gender Identity: Pronouns: Concession Card: Pension/Health Care/ DVA Card No: Expiry Date (dd/mm/yy) Private Health Fund: To assist us with our health initiatives - are you Aboriginal or Torres Strait Islander?: Aboriginal: YesNo Torres Strait Islander:YesNo Address Home Phone No: Next of Kin Name/Relationship & Phone No: Emergency Contact Name Relationship & Phone No: Mobile No: Any Allergies Smoker: YesNo Alcohol: YesNo Diabetic: YesNo Do you need and interpreter: YesNo Consent: YesNo Our surgery requires the above information to maintain your records. This form will be scanned into your patient file and securely stored. I give permission for my personal health information to be used for treatment purposes. This includes disclosure to others involved in my healthcare within and outside this medical practice. This may occur through referral to other health professionals or for medical tests and in the reports or results returned to my doctor following referrals. Recalls: We will let you know when your results have arrived and are available for review with the doctor. Please let us know your preferred method of contact. SMS via HealthEnginePhone Reminders: Our practice is commited to preventative care. You will receive reminder notices for health services appropriate to your care (e.g. Cervical Screening, Bowel Cancer Screening, blood tests, care plans, etc). Please advice the practice if you do not want to be included in the reminder system. If you are happy to be reminded please let us know your preferred method of contact. SMS via HealthEnginePhone Yes I consent to the practice contacting me by text message or phone call for the purpose of recalls for results, preventative health reminders, appointment reminders and any follow-ups if required. Yes I acknowledge that reminders by text are in additional service and that they may not be sent on all occasions and that the responsibility for attending appointments, cancelling them and calling for results still lies with me. Yes I understand I can opt out of the reminders service at any time. Yes I have read the information regarding recalls and reminders and agree to the terms and conditions listed above. Yes I consent to be contacted via email when I am unable to be contacted via phone or sms at my request. Yes I prefer to receive my prescriptions as a QR code email to me instead of printed. (This will print your filled form on a new tab and will also send email to MediClinic.)
