New Patient Registration

Personal Details

First Name *

Middle Name

Last Name *As shown in your medicare

Preferred Name

Date of Birth *

Street Address *

Suburb *

ZIP/Postal Code *

Mobile Phone

Home Phone

Work Phone

Email Address *

Medicare / Insurance Details

Medicare Number *

0 / 10

Medicare Ref No: *

Expiry Date *

DVA Gold / White Number *

0 / 10

Expiry Date *

Pension / HCC Number *

0 / 10

Expiry Date *

Insurance Company *

0 / 100

OSHC / OVHC Number *

0 / 10

Expiry Date *

Next of Kin / Emergency Contact Details

Next of Kin *

Street Address *

Suburb *

ZIP/Postal Code *

Relationship with the patient *

0 / 100

Contact Number *

Is your emergency contact same as your next of kin ? *YesNo

Emergency contact Name *

0 / 1000

Relationship with the patient *

0 / 100

Emergency Contact Number *

Street Address *

Suburb *

ZIP / Postal Code *

General Details

To assist with health initiatives - Are you Aboriginal or Torres Strait Islander ? *Yes - AboriginalYes - Torres Strait IslanderYes - Aboriginal & Torres Strait IslanderNeither

Marital Status

0 / 100

Occupation

0 / 100

Country of Birth

0 / 100

Year of arrival in Australia

0 / 4

Do you have any allergies ? *YesNo

Please list your allergies *

0 / 1000

Do you have any on-going health problems ?YesNo

Please list your on-going health problems

0 / 1000

Have you had any significant previous health problems ?YesNo

Please tell us about your previous health problems

0 / 1000

Do you consume any other recreational substances ?NoYesOccasionally

Please list the recreational substances

0 / 1000

Tell us how you found us? *

0 / 1000

Would you like to be contacted via SMS (Mobile Text Messages) for appointment reminders, recalls and other test reminders or services we offer ? *YesNo

Privacy 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 Agree