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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

All new patients intending to move to our clinic require 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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