Patient Registration Name(Required) First Last Date of birth(Required)OccupationPhone number(Required)Email(Required)Address Street Address Suburb Postcode Next of kin name First Last Next of kin contact numberGP Name First Last GP Clinic nameDentist Name First Last Dentist Clinic nameMedicare numberMedicare reference numberMedicare expiry datePrivate health fund numberPrivate health member numberPrivate health reference numberHospital cover: Yes No DVA card numberDVA card colourDVA card expiryWorker cover claim: Yes No Medical history or conditionsMedications including tablets, injections (including 6 monthly osteoporosis injections), blood thinners, diabetes medications:Allergies or bad reactions to medications/tapes :Are you pregnant? Yes No Do you smoke? Yes No Any major operations in the last 5 years? What operation, what hospital, any issues:Weight:Height:ConsentFee Policy: The fee for your consultation is payable on the day. Patients who fail to attend appointments without 2 hours prior notice will incur a non-attendance fee of $30. By signing this form, you are agreeing to the fee policy. Surgical fees are discussed only if the surgeon has recommended a procedure. Privacy Statement: This practice handles personal information in accordance with the Privacy Amendment (Private Sector) Act 2000. I consent to the handling of my information by this practice for the purpose of providing quality health care, associated administrative and billing purposes, and give permission for medical information to be obtained from any other source to help with my treatment. I also give permission for medical photography to be used for planning procedures and follow up. Use for teaching, audit research or publication would require additional consent to be obtained. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. For more information, please refer to our privacy and confidentiality statement available at reception. I consent to the use of an artificial intelligence (AI) scribe during all consultations. The AI scribe will transcribe the discussion to assist with creating a written clinical note. The written note is edited to ensure accuracy. The information is stored only as text as a clinical note. Any audio data is deleted immediately after the written clinical note has been generated. Consent:(Required) I have read the above fee policy and privacy statement. I consent to the taking and use of my medical records as described. I have viewed the fees and agree to pay the costs of consultations, and any surgical procedures performed. Patient Signature(Required)Date(Required) MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
