Patient Registration

Confidential Registration

Title:*

Surname:*

First Name:*

Date of Birth:*

Address:*

Suburb:*

State:*

Postcode:*

Telephone:*

Email:*

Occupation:*

Family Doctor:*

Family Doctor Telephone:*

Practice Name:*

Address:*

Suburb:*

State:*

Postcode:*

Referring Doctor:*

Practice Name:*

Referring Doctor Telephone:*

Address:*

Suburb:*

State:*

Postcode:*

Medicare No:*

No. on card:*

Expiry:*

Insurer Name

Claim No:

Health Fund:

Member No:

Veterans Affairs No:

How did you hear about us:*

Do you have or have had any of the following:

List current illnesses:

List current medications:

Nb. Include - aspirin, cortisone/steroids, anti-inflammatory, warfarin, herbal products & over-the-counter preparations.

Do you smoke?*

How many per day?

Alcohol intake per week?*

Allergies:*

Previous operations:*

Are you interested in information on treatment possibilities relating to any of the following?

(please tick the areas you are interested in)

Patient Privacy Act

As a result of new privacy laws introduced by the Government, this office requires you to read this sheet regarding your personal and medical information and then sign to say you have read and agree with the statement. Your files contain the following information:

Personal details (name, address, date of birth, Medicare number & health details)
Your medical history
Notes made during the course of your medical consultation
Referrals to other Health Service Providers
Results and reports received from other Health Service Providers

This information is provided by you or arises as a consequence of information provided by you. It may be necessary for us to obtain copies of reports such as x-rays, pathology and correspondence from other Medical Professionals or confer with Surgical Colleagues or your General Practitioner regarding your medical treatment. Due to changes in the Privacy Act, it has become necessary for us to obtain written consent from each patient in our practice to obtain these records. Please note: Medical records cannot be released without your consent, except when they are required under Law such as a subpoena.

Confidential Registration

Patient Privacy Act

Declaration

BELLA VISTA

ALBURY

ERINA – CENTRAL COAST