New Patient Information Form

 

We are committed to providing our patients with the best care, to do this it is essential that your medical records are up to date and accurate.  Could you please assist us by completing the following?

 

PLEASE COMPLETE ALL PAGES

 

Patient Name: _____________________________________________________________________________

                           (First Name)                                        (Last Name)

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Title: Mr. Mrs. Ms. Miss. Mast. Gender: Male / Female / Other Date of Birth: ______/______/_________


Street Address: ____________________________________________________________________________


Suburb: ___________________________________________ Post Code: _______________________


Postal Address: ___________________________________________________________________________
(If different from above)


Suburb: ___________________________________________ Post Code: _______________________
 

Contact Details: ___________________________________________________________________________
                              (Mobile)                             (Home)                                (Work)
 

Email Address: ____________________________________________________________________________
 

Medicare Number: ___________________________________ Ref No. _______ Expiry Date: _____________
 

Concession Card Number (please circle): * Pension (Blue), Health Care Card (Green) Commonwealth (Red)*
 

Number: __________________________________________ Expiry Date: _______________________
Veterans’ Affairs – DVA (please circle): * White Card or Gold Card*
 

Number: __________________________________________ Expiry Date: _______________________
 

Occupation: _______________________________________________________________________________
 

Do you identify yourself as:
 

Australian: Yes / No Aboriginal or Torres Strait Islander: Yes / No Other: _______________________
 

Next of Kin: _________________________________________________________________________________________________________
                       (Full name)                          (Contact Number)                     (Relationship)
 

Emergency Contact: (other than next of kin)
 

__________________________________________________________________________________________________
 (Full name)                                  (Contact Number)                                      (Relationship)
 

Do you consent to receive SMS reminders? Yes / No
 

New Patient Information Form
 

We require your consent to collect personal information about you. Please read this information carefully, and sign where indicated below.
 

The Gisborne Medical Centre collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. This information may be used in the following ways:


 Administrative purposes in running our medical practice.

 Billing purposes, including compliance with Medicare Australia requirements.

 Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals.

 To contact you or your family for the purposes of Recalls & Reminders
 

Patient information shall not be released to a third party without the expressed consent of the patient.
 

The Gisborne Medical Centre Privacy and Access policy is available by asking reception for a copy is on display in our waiting room and is also available on our website www.gisbornemedical.com.au
 

I have read the information above and understand the reasons why my information is collected.
 

I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me.
 

I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.
 

I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained.
 

I consent to the handling of my information by this practice for the purposes set out above.
 

 

Signed : __________________________________________  Date: ___ / ___/ _______
 

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Patient Name: ____________________________________ DOB: ___ / ___/ _______
 

New Patient Information Form
 

The purpose of this form is to inform you and seek your consent to the use and disclosure of your personal information (including health information) in regards to our reminders and notifications systems within our practice.
 

This general practice is committed to providing our patients with quality health care. As part of our commitment, we have implemented technology solutions to enable communications with our patients via SMS.
 

In keeping with our obligations under Privacy Act 1988 and Australian Privacy Principles and under State and Territory health records legislation, we wish to inform you of the purposes for which we may use your personal information and how we may use and disclose your personal information (including health information). Please refer to our privacy policy or privacy statement https://www.gisbornemedical.com.au/privacy--access-policy for more information generally on the management of personal information (including health information) by this general practice.
 

In addition to other communications we may send you from time to time, we may send you the following types of communications:


1. appointment reminders – notifications to you to remind you of upcoming appointment dates with the practice as well as allowing you to confirm your appointment;
2. clinical reminders - notifications to you to remind you to contact the practice to arrange appointments for regular clinical check-ups, medical procedures, immunisations due;
3. clinical communications - communications to you about your clinical care at the practice such as returned pathology results or clinical messages from the medical practitioner; and
4. health awareness – communications to you in relation to general health care information and health care services provided by this general practice including notification about changes to our clinic opening hours, and information about health care services provided by this general practice.
As part of the provision of health care services to you, we will send you appointment reminders, clinical reminders and clinical communications from time to time. We may also send you health awareness information if you have consented to receive such communications below. We may use third party service providers (which may be located outside of this State or Territory) and disclose your personal information (including health information) to them, to assist us in sending you the above communications.
To the extent practicable, we will send you communications via your preferred contact method indicated below. However, you acknowledge that we may contact you using any of your contact details that you may provide to us from time to time as we consider appropriate.
 

Acknowledgements and Consent
 

I acknowledge and agree that, in the course of providing health care services to me, the general practice may need to use and disclose my personal information (including any health information) as set out in this form.
 

I wish to receive health awareness communications (as described above) and I hereby specifically consent to the use of my personal information (including any health information) by this general practice to assess the types of health awareness communication it sends me and specifically consent to receipt of such health awareness communications.

 

☐    YES ☐     NO
 

I acknowledge that the practice will use contact details provided by me (as updated by me from time to time) to communicate with me. To the extent that the mobile number I have provided to this general practice is utilised by more than one patient, I understand and consent that all SMS and phone communications will be directed to that number.
 

Please complete and sign below if you understand and agree to the acknowledgements and consent set out above.
 

Patient Name:
 

Parent/Guardian Name (if Patient is under 16)
 

Signature:
Date:
 

PLEASE TAKE THIS FORM IN TO CONSULT WITH DOCTOR
 

Patient Name: ____________________________________________________________________
 

MEDICAL INFORMATION
 

Smoking: Yes / No Ex Smoker: Yes / No When ceased: ____________________________________
 

Alcohol: Yes / No If yes, how many days per week? __________ how many drinks per day? ________
 

Do you have any allergies or are you sensitive to drugs or dressings: Yes / No (if yes, please list below)


____________________________________________________________________________________________________________________________

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____________________________________________________________________________________________________________________________
 

Family History: (if so, whom) ________________________________________________________________
 

Diabetes Stroke Heart Disease Cancer High Blood Pressure 
 

Other: ___________________________________________________________________________________
 

Regular Medications: ______________________________________________________________________________________________________
 

____________________________________________________________________________________________________________________________


Current Medical Issues: ___________________________________________________________________________________________________
 

____________________________________________________________________________________________________________________________


Past Medical Issues: ______________________________________________________________________________________________________
 

____________________________________________________________________________________________________________________________

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Operations: ________________________________________________________________________________________________________________
 

____________________________________________________________________________________________________________________________

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WOMEN’S HEALTH:
 

Oral Contraceptive Pill: Yes / No Recent Pap Smear: Yes / No (if so, when______________)
 

Would you like to be on our reminder system? Yes / No
 

MENS HEALTH:
Prostate Check: Yes / No (if so, when______________)