Patient Registration Form

Patient Details

First Name

Last Name

Street Address

Suburb

State

Postcode

Date of Birth

Email Address

Home Phone

Work

Mobile

Do you consent to receive correspondence via email

YesNo

Are you happy to receive SMS messages regarding your appointments?

YesNo

Account Information

Medicare Number

Reference No

Valid to

Do you have Private Health insurance?

YesNo

Health Fund Name

Membership No

Customer No

What level of cover do you have

Full CoverHospital OnlyExtras Only

Do you have a Health Care/Pension card?

YesNo

Health Care Card Number

Expiry Date

Do you have a Veterans Affairs Card?

Yes No

Veterans Affairs Card Number *

DVA Card Colour *

If White card - what is the condition for?

Who is responsible for the payment of your account

SelfParents

What name is on the Medicare Card

Medicare Number

Valid to

Reference No

DOB (for Medicare purposes) *

Medical Practitoner Details

Dental Practitioner and location

General Practitioner and location

Other treating Specialists

Medical History

Are you on any medications for osteoporosis or bone strengthening? These may be tablets taken daily or weekly, or injections every 6 or 12 months. (Eg. Fosamax, Actonel, Alendronate, Prolia, Zometa) *

YesNo

Allergies

Do you have any allergies? *

Current Medications

Are you on any regular medications? *

Any Other Conditions

Are there any other health conditions we need to be aware of? *

Emergency Contact Details

First Name

Last Name

Relationship to patient

Contact phone