New patient registration - over age 16 - Colleges Crossing Family Practice

New patient registration - over age 16

Thank you for taking the time to complete the following paperwork because it helps us to provide the best possible care for you and your family.

Title

Name (exactly as it appears on your Medicare card)

First

Last

Preferred name

Birth sex

Gender

Date of birth

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Best contact phone (mobile)

Secondary contact phone

Email address

Email

Confirm Email

Type of primary healthcare scheme

Medicare number

Medicare reference number

Medicare expiry date

DVA number

Health care card number (if applicable)

Healthcare Card expiry date

Next of kin name

First

Last

How is your next of kin related to you?

Other family members

Current occupation and employer

What is your background?

This information helps us to provide appropriate care for a wide variety of people from different backgrounds and ethnicities.

Other ethnicity

Please list all allergies and reactions, especially to medications

Or enter "No known allergies''

Are you protected against illness by being vaccinated?

Please briefly list any current or past medical conditions and surgeries including mental illness

Or enter ''No previous medical conditions''

Please list your current medications including vitamins and supplements

Or enter "No current medications"

Family history of illness

Please further describe any family history of illness

For example - ages of family members affected.

How many pregnancies have you had?

How many children do you have?

Do you smoke?

Do you drink alcohol?

Current height

in centimeters

Current weight

in kilograms

What hobbies and sports do you like?

Is there anything else that you would like your GP to know?

For example - needle phobia, things we can do to assist you to feel comfortable in our clinic etc.

Health information collection and use consent

We need to record your personal and medical details so that we can create a medical record and provide quality health care to you. We take protecting your personal and medical details very seriously, and you can download a copy of our privacy policy from our website, or request a copy from our reception. We use the information to: provide patient care, run our medical practice, billing including Medicare and Health Insurance Commission compliance, make referrals to other health care providers like other doctors, or pathology companies, instruct any students attached to our practice, for quality assurance activities to improve individual and community health, to comply with legislative or regulatory requirements e.g. notifiable diseases, for reminder SMS/emails/letters/phonecalls which will be sent to you regarding your healthcare and management. If data is used for quality improvement or research purposes the information will be de-identified, in the situation that any identifiable data is needed your consent will be requested.

Please consent to CCFP creating a medical record for you by agreeing to the following items

I understand why I am being asked for personal and medical details, and that I am not obliged to provide any information requested of me, but that failure to do so may reduce the quality of health care and treatment given to me.
I am aware of my rights to access the information collected about me, except in some circumstances where access may be legitimately witheld. I will be given an explanation in these circumstances.
I understand that if my information is to be used for any other purpose other than set out here, my further consent will be obtained.
I consent to the handling of my information by the practice for the purposes set out above, subject to any limitations on access or disclosure.
I am unsure and would like to discuss this further with somone from practice before I sign