Patient Registration Form

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Title

Given Name

Surname

Date of Birth

Occupation

Street Address

Suburb

Postcode

Postal Address (if different from above)

Mobile Number

Email Address

Medicare Number

Cardholder No.

Private Health Fund

Member No.

Veteran's Affairs card No.

Card colour

Workcover / TAC claim No.

Insurance company

Your usual GP (full name)

GP Practice

Other Health Team Member

Tel.

Next of Kin (Name)

Relationship to you

Next of Kin mobile No.

Next of Kin email

Do you have Diabetes?

Yes No

Diabetes medications

Do you suffer from any allergies?

Are you on any current medications?

Other important information

IMPORTANT: Privacy policy
From 21/12/2001 the Federal Privacy Act of 1988 has been amended to apply to all Doctors in private practice. It is required that a fully informed voluntary consent is obtained before or as soon as practical after the collection of health information. Medical care requires full knowledge of patient health information by all members of a medical team, which may be shared from time to time. This may include referring doctors, pathology, radiology, anaesthetists, Medicare, private health funds and debt collection agencies. Health information may be used for “secondary purposes” such as auditing for quality purposes, access medical records, x-rays and surgical photographs / videos. The privacy of individuals is strictly maintained when reporting results of audits or research to the profession.
I (print name) ___________ have read and understood the above and consent to information, radiology images and photographs being used for the secondary purposes of audit and research by Mr Jason Hockings and his associates. I also consent to medical records and radiology images being destroyed after seven

Signature

Name: (Please Print)

Patient Registration Form

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