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Ph: (03) 5750 1000

Mon - Fri: 9am - 5pm
Sat: 9.30am - 11.30am
Sun: CLOSED     

New Patient Form

Please fill in the details below.

  • Contact Information
  • First name *
  • Surname *
  • Date of Brith *
  • Email *
  • Phone Number *
  • Mobile Phone Number
  • Work Phone Number
  • Street Address *
  • Suburb *
  • Postcode *
  • State *
  • Mailing Address
  • Medicare Care Number
    Make sure you include 10 digits plus the reference number next to your name.
  • Medicare Care Expiry Date
  • Private Health Insurance
  • Do you have private cover?
  • If yes, please provide the name of the fund:
  • Pension Card and Health Care Card Holders
  • DVA Gold Car Number
  • DVA White Card Number
  • Pension Card Number
  • Expiry Date on Card
  • Personal Information
  • Are you of Aboriginal or Torres Strait Islander origin? *
         
  • If no, what is your ethinicity?
  • Do you require the medical records to be transferred from another clinic? *
         
  • If yes, please provide details of your previous clinic.
  • Your previous medical history
  • Your height in cm
  • Your weight in kg
  • Do you currently have/ have you ever had:
  • Please list any allergies or sensitivities to medications or dressings:
  • When was the last time you had your blood pressure taken?
  • Females - when did you have your last pap smear?
  • Females: when did you have your last breast check?
  • Males: When did you have your last general checkup?
  • Current Medications
  • Please list any prescribed medications you are currently taking:
  • Please list any over-the-counter medications you are currently taking:
  • Immunisation Status
  • Please tick immunisations you have had
  • If completing for a child, are their immunisations up to date?
  • If over 65, when was your last influenza immunisation?
  • If over 65, when was your last pneumococcal pneumonia immunisation?
  • Family Medical History
  • Have any of your family members ever had
  • Social History (please only answer relevant sections)
  • Smoking
    How many per day/week or date ceased smoking
  • Alcohol
    Number of standard drinks per day/week/month
  • Drug use
    Type and quantity/ frequency
  • Emergency Contact
  • Name
  • Home phone number
  • Mobile Phone Number
  • Relationship to you
  • Information storage agreement

Please have a look at our privacy brochure which tells you how we handle your medical records and keep your information secure. All new patients intending to move to our clinic are requeseted to make a double appointment to go through their medical history with one of the practice nurses. Please advise the administration staff when making your first appointment.

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