Personal DetailsTitle *MrMrsMsMissMasterDrOtherGender *MaleFemaleTransgenderFirst Name *Middle NameLast Name *As shown in your medicare Preferred NameDate of Birth *Street Address *Suburb *ZIP/Postal Code *Mobile PhoneHome PhoneWork PhoneEmail Address *Medicare / Insurance DetailsPlease choose your Medical Insurance Provider *MedicareDVA Gold / WhitePension / HCC OSHC OVHC PrivateMedicare Number *0 / 10Medicare Ref No: *Expiry Date *DVA Gold / White Number *0 / 10Expiry Date *Pension / HCC Number *0 / 10Expiry Date *Insurance Company *0 / 100OSHC / OVHC Number *0 / 10Expiry Date *Next of Kin / Emergency Contact DetailsNext of Kin *Street Address *Suburb *ZIP/Postal Code *Relationship with the patient *0 / 100Contact Number *Is your emergency contact same as your next of kin ? *YesNoEmergency contact Name *0 / 1000Relationship with the patient *0 / 100Emergency Contact Number *Street Address *Suburb *ZIP / Postal Code *General DetailsTo assist with health initiatives - Are you Aboriginal or Torres Strait Islander ? *Yes - AboriginalYes - Torres Strait IslanderYes - Aboriginal & Torres Strait IslanderNeitherMarital Status0 / 100Occupation0 / 100Country of Birth0 / 100Year of arrival in Australia0 / 4Do you have any allergies ? *YesNoPlease list your allergies *0 / 1000Do you have any on-going health problems ?YesNoPlease list your on-going health problems0 / 1000Have you had any significant previous health problems ?YesNoPlease tell us about your previous health problems0 / 1000Do you smoke ?NoYesOccasionally Do you consume alcohol ?NoYesOccasionally Do you consume any other recreational substances ?NoYesOccasionally Please list the recreational substances0 / 1000How did you find us ? *Word of MouthDrive / Walk PastInternetFlyersOtherTell us how you found us? *0 / 1000Would you like to be contacted via SMS (Mobile Text Messages) for appointment reminders, recalls and other test reminders or services we offer ? *YesNoPrivacy Agreement And Patient Consent I understand that Alpha Medical Clinic and associated Medical Centers comply with the privacy Act (1988) and as part of their privacy policy they are committed to protecting the privacy of individuals and their personal information. My signature below indicates that I have read the above and consent to Alpha Medical Clinic collecting, using, storing and disposing of my personal information; the release of relevant personal information to other health professionals to allow quality medical care; inclusion in a recall register to be advised of follow up visits: inclusion in national/state reminder systems/registers, medical updates and health information and the release of relevant personal information to my (prospective) employer, their authorised representative and their insurer in the case of a work related consultation or service. I understand I may withdraw my consent for Alpha Medical Clinic to use and disclose my personal information (except when legal obligations must be met). I understand that there will be an administrative charge for transfer or print of medical records *Yes, I AgreeSubmit