New Patient Registration Form "*" indicates required fields Step 1 of 4 0% Patient DetailsTitle* Surname* Given Name/s* Date of Birth* DD slash MM slash YYYY Gender*Please selectMaleFemaleOtherIf other, please specify* Marital Status*Please selectSingleMarriedDefactoSeparatedDivorcedWidowedMedicare No.* Ref No. Expiration Date Pension, Health Care Card or DVA White/Gold Card No: Expiration Date Occupation Employer Home Address* Postcode* Postal Address* Postcode* Email* Phone (Home)Phone (Work)Phone (Mobile)* Next of KinName* Relationship to you* Phone (Mobile)*Phone (Home)Phone (Work)Emergency ContactName* Relationship to you* Phone (Mobile)*Phone (Home)Phone (Work)Do you identify as someone from a culturally and/or linguistic diverse background?* Yes No If yes, Please indicate ethnicity* To assist with health initiatives - are you Aboriginal or Torres Strait Islander?* Yes - Aboriginal Yes - Torres Strait Islander Yes - Aboriginal & Torres Strait Islander No Health QuestionnaireAllergy to medication or food?* Yes No Unknown If yes, Please specify* Smoker Status* Never Smoked Ex-Smoker Smoker If Ex-Smoker, Please specify year quit If Smoker, Please specify no per day Alcohol Intake* Nil Yes If yes, please choose standard drinks/per* Day Week Month No of drinks*Recreational Drugs* Yes No Regular Medications* Nil Yes If yes, Please list below any medications and their doses if known – include over the counter medications and supplements* Add RemoveCurrent/Previous Medical Conditions* Nil Yes If yes, please tick any that apply* Asthma Diabetes Type 1/Type 2 Heart Attack (MI) Stroke/CVA Pacemaker DVT Emphysema Depression and/or Anxiety Cancer HIV/AIDS Hepatitis A / B / C Epilepsy Other Please specify Cancer type If other, please specify* Family Medical History* Nil Yes If yes, Please list below*Relation to you (e.g., mother, grandfather, sibling)Condition/s Add Remove Our practice undertakes research, professional development, and quality assurance/improvement activities to improve patient care. All people accessing personal health information for this purpose have signed a written confidentiality agreement.I consent to my health record being reviewed and uploaded to My eHealth Record as a part of the quality improvement activities in this practice.* Yes No I give permission for my personal information to be collected, used and disclosed as described in this practice policy. I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.* Yes No Our practice uses a reminder system to improve the quality of your health care. The practice sends reminders by mail or telephone for procedures such as vaccinations, pap smears and other health reviews.* Yes No I consent to being contacted with reminders by sms/phone/email* Yes No CAPTCHA Δ