Patient Registration Form

Patient Details

Title

First Name

Last Name

Preferred Name

D.O.B.

Address

Suburb

State

Postcode

Email

Mobile Phone

Home Phone

Do you identify as Aboriginal or Torres Strait Islander?

YesNo

Language / Ethnicity

Medicare and Private Health Insurance Details

Medicare Card Number

Ref No

Exp

Do you have insurance that covers medical expenses only / dental expenses only / full cover?

YesNo

Health Fund Name

Number

Do you have a Pension Card, Health Care Card or Department Veteran’s Affair Card?

YesNo

Type

Number

Exp

If DVA card, what colour?

Person responsible for account (compulsory for patients under 18)

Title

First Name

Last Name

D.O.B.

Email

Medicare Card Number

Ref No

Exp

General Dental and Medical Practitioner

Dental Practitioner

Location

Medical Practitioner

Location

Other treating Specialists

Emergency Contact / NOK / Substitute Decision Maker

Title

First Name

Last Name

Relationship to patient

Phone Number

Do you have an advanced health directive?

YesNo

Medical History

Endocrine / Metabolic

DiabetesOsteoporosisCurrently taking Ozempic or other weight loss medication

Musculoskeletal

Artificial joints (hip, knee etc.)

Skin Integrity

Skin intactFragile skinWounds / ulcersPressure injury risk

Please specify Wounds / ulcers

Respiratory

AsthmaOther respiratory problems

Haematological

Bleeding or clotting disorderAnaemia

Immune / Infectious

Immune system issues (immunocompromised)Known infectious condition

MRSARSVOther

Please specify

Social History / Lifestyle

SmokingRecreational drug use

Falls Risk

History of falls in the last 6–12 monthsMobility issues / requires assistanceUses walking aidAt risk of falls (clinician assessment)

Neurological

Epilepsy / seizures

Oncology

CancerHistory of radiotherapy

Cancer Type

Gastrointestinal / Hepatic / Renal

Kidney diseaseLiver diseaseHepatitis (please circle): A / B / C

Mental Health

Depression / Anxiety

Allergies

Current Medications

Any other conditions

Consent

Our Practice uses SMS reminder system for appointments. Do you consent to receive SMS: *

YesNo

Do you consent to receive correspondence via email: *

YesNo

The above information is true to the best of my knowledge. *

Patient/Guardian Signature

Draw signature|Type signatureClear

Date