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In order to provide you with the highest quality of care, we require the following information from you. This form complies with the
RACGP Standards for general practices (5th edition). This means your personal health information is kept private and secure, as
required by federal and state privacy laws. If you haveconcerns, please leave blank and discuss with your GP.
SECTION A: Personal details
NEW PATIENT REGISTRATION FORM
Title
Medicare card number Medicare reference number
Date of birth (if applicable)
Medicare expiry date
Expiry date
Postcode
Postcode
Relationship to you
Relationship to you
Gender
Surname Given name
Please print letters.
Use black or blue pen.
Place ‘X’ in all applicable boxes.
/ /
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M
F
Pension, Health Care Card, or Veterans Affairs number (if applicable) Policy number
Occupation
Home address
Postal address
Telephone number
Email
Work number Mobile number
Next of Kin
Who can we contact in an emergency?
Name
Name
Telephone number
Telephone number
Work number
Work number
Mobile number
Mobile number
Please notify us promptly of any changes in your contact details. Accurate contact details help us identify you and your medical
records, and allow us to contact you promptly when required.
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SECTION B: Cultural background
SECTION C: Allergies and medicines
SECTION D: Consent
SECTION E: Transfer of health information
No
Yes
Yes
No
No
Yes, Aboriginal
Yes, both Aboriginal and Torres Straig Islander
Knowing your cultural background can help us provide healthcare that meets your individual needs.
You may have consistently consulted with a GP at another practice. The health information held by that GP may assist us
with your future healthcare needs. You may wish to have a copy or a summary of your health records transferred to this
practice. Please ask the receptionist for information about how this can take place.
Are you of Aboriginal or Torres Strait Islander origin?
Your country of birth
List allergies and intolerances to medications
Our practice may use a reminder system to help you maintain
your health. The practice may send reminders by post, email,
telephone or SMS for procedures such as vaccinations, Pap
tests and other health reviews.
Our practice also sends information to the Australian Childhood
Immunisation Register and Pap Smear Register. These
registers also send reminders, which can be helpful if you move.
Signature of patient or guardian
Please advise us if your contact information for Medicare details change.
I consent to being contacted with
reminders to help me maintain my health
I consent to being contacted with
reminders to help me maintain my health
st regular medications and doses
Date
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