New Patient Registration

Personal Details

Title:
MrMrsMsMissMast

Surname:

Given Names:

Date of Birth:

Gender:
MaleFemale

Occupation:

Nationality/country of birth:

Language:

Are you of Aboriginal or Torres Strait Islander Origin?
AboriginalTorres Strait IslanderBothNeither
(If you have ticked yes please see reception regarding: Closing the Gap program)

Contact Details

Street Address:

Suburb:

Post code:

Postal Address (if different):

Suburb:

Post code:

Email:

Home Phone:

Work Phone:

Mobile:

Preferred mode of contact: HomeWorkMobile

Health Details

Medicare No:

Reference number:

Expiry:

Pension / Health Care / Veterans Card:

Expiry of Pension / Health Care / Veterans Card:

Next of Kin

Next of Kin name:

Relationship with next of Kin:

Next of Kin Phone Number:

Emergency Contact (if different)

Name:

Relationship with emergency contact:

Emergency Contact Phone Number:

Allergies

Do you suffer from allergies? (If yes, list below)

What is the extent of the reaction?

Do you take medication for allergies? (If yes, list below)

Surgical History

Please list any surgical procedures / operations you have had:

Surgery Procedure

Approx. Year

Surgery Procedure

Approx. Year

Medical History

Please list any medical conditions you may have/had:

Family History

Below, please list any known history (e.g. parents, siblings, grandparents, aunts, uncles)

Diabetes

Heart Attack

Hypertension

Cancer

Stroke

Other

IMMUNISATIONS

Please list any known vaccinations you have had

Social Habits

Smoking (if yes, include how many per week. If ex-smoker, include approx. quit date)

Drinking Alcohol (if yes, include how many per week, how many per occasion)

Other (if yes, include how often)

FEMALE PATIENTS ONLY:
Please list any significant gynaecological history (last pap test etc)

Correspondance

Would you like to receive a newsletter from Meroo St Family Practice? YesNo

If yes, would you like it sent via email or post? EmailPost

Appointment reminders via SMS I consent to receiving SMS reminders

Read our privacy and confidentiality policy here I've read and accepted the privacy & confidentiality policy (required)