New patient registration

Patient Registration Form

PATIENT DETAILS

Title *

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

MaleFemaleOtherUnknown

Is your gender listed differently with Medicare? *

Yes No

What is your gender as listed with medicare (if different)?

Is English your preferred spoken language?

YesNo

Ethnicity

ATSI *

AboriginalTorres Strait IslanderAboriginal and Torres Strait IslanderNeither Aboriginal or Torres Strait Islander

Why are you transferring your care to Whitebridge Medical Centre?

Why you are transferring your care to our surgery? *

Details

PATIENT CONTACT DETAILS

Mobile *

Other number (optional)

Email *

Address *

Suburb *

Postcode *

State *

EMERGENCY CONTACT / NEXT OF KIN

Name *

Mobile Phone *

Relationship *

MEDICARE

Do you have a different name on your medicare card?

YesNo

If you have an alternative name listed on your Medicare card please list this below

Medicare First Name

Medicare Surname

Medicare Card No.

Expiry *Must be entered in this format YYYY-MM

Position on card

Medicare Address (if different to your residential address)

PENSION / HCC / DVA Card

Do you have an aged pension card, healthcare card or a DVA card

YesNo

Card Type

HCCPension

Card No.

ExpiryExpiry date must be entered in this format

DVA Card Type

GoldWhiteLilacOrangeBlue

DVA No.

RECORDS

If you have any clinical records you would like uploaded to your file please add these below

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SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

I agree to communicate with the practice via email *

Patient/ Guardian Signature

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Today's Date

Our privacy policy can be viewed at https://mayflower-tan-nay2.squarespace.com/privacy-policy-1

Our clinicians my use an AI scribe program during consultations to assist with note taking. If you would like to have this turned off please advise your clinician at the start of the consult. Further details can be found at https://www.heidihealth.com/au/safety

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