New Patient Information Form

New Patient Form

If you prefer you may download, print and fill in the form with you.

- click here -

Family name*

Given names*

Date of birth (dd/mm/yyy)

Parents names (if patient under 18 years old)

Email address*

Address

Suburb

State

Postcode

Home phone

Mobile phone

Work phone

Medicare number (1234 12345 1)

Number in front of your name on card

Expiry date (mm/yyyy)

Do you consent to "My Health Record"

YESNO

Veterans Affairs number

Gold cardWhite card

Health conditions covered (for white card holders only)

Australian Pension Number (blue cards only) CRN (123-123-1234)

Expiry date (dd/mm/yyyy)

Private Health Insurance

YESNO

Occupation

Emergency contact (not next of kin)

Emergency contact phone number

Next of kin

Next of kin phone number

Relationship

Names of all medications you currently take (just names, not doses)

Allergies

Name of former Doctor

Clinic / Practise name

Doctor's phone number

Country of birth*

Ethnicity*

CULTURAL BACKGROUND

TORRES STRAIT ISLANDER ABORIGINAL

Patient consent*

PATIENT PRIVACY CONSENT FORM:
This Medical Practice collects information from you the for the primary purpose of providing quality health care. We require you to provide us with accurate and up to date personal details and full medical history so that we may safely and properly manage your health care needs. We may use information you provide us in the following ways:
• Administrative purposes in running our practice
• Billing purposes in compliance with Medicare Australia and HIC requirement’s
• Disclosure to others involved in your health care, including specialists and other health care providers outside of our practice. This may be in the form of referral letters and/or by collecting no identifiable statistical information of clinical data for improved health care.
• To discuss your care and management with relevant providers specific to your care in case conferences between other health care providers. This Medical practice complies with National Health Privacy Principles in collection, storage and transfer of your personal information.

I HAVE READ AND UNDERSTOOD THE INFORMATION ABOVE. I UNDERSTAND THAT I AM NOT OBLIGED TO PROVIDE ANY INFORMATION REQUESTED OF ME BUT FAILURE TO DO SO MIGHT COMPRIMISE THE REQUIRED HEALTH CARE GIVEN TO ME. I UNDERTAKE TO NOTIFY THE PRACTICE OF CHANGES TO MY PERSONAL DETAILS. I AM AWARE OF MY RIGHT TO ACCESS THE INFORMATION COLLECTED ABOUT ME , EXCEPT IN LEGITIMATE CIRCUMSTANCES THAT WILL BE EXPLAINED SHOULD THEY ARISE

PATIENT DECLARATION:
I UNDERSTAND THAT IF MY INFORMATION IS TO BE USED FOR ANY OTHER PURPOSE OTHER THAN AS SET OUT ABOVE, MY FURTHER CONSENT WILL BE OBTAINED. ANY LIMITATION THAT I PLACE ON THE HANDLING OF MY PERSONAL INFORMATION I UNDERTAKE TO SET OUT IN WRITING.

I agree

What is the word below this form?*

- any feedback is welcome to improve the quality of our service -

New Patient Information Form - Somerville Medical Centre

Somerville Medical Centre

1176 Frankston-Flinders rd

(03)59776666

Somerville Medical Centre

1176 Frankston-Flinders rd

(03)59776666