Patient Registration Form

PATIENT REGISTRATION FORM

If you are a new patient with an appointment already booked or an existing patient updating details please complete ALL of this form. Please do not complete this form if you do not have an appointment or currently attend the practice.

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Personal Information

Are you a New or Existing patient completing the form?*

Surname*

Preferred Name*

Birth Sex*

Preferred Pronoun*

Given Name(s)*

Date Of Birth*

Gender Identity*

Please Specify*

Residential Address

Address*

Suburb*

Post Code*

Postal Address

Please enter your Postal address if diffrent from your Residential addresss

Address

Suburb

Post Code

Contact Details

Phone*

Work

Mobile

Email address*

for confidentiality, provide personal email address only

Culture & Language

Country of Birth*

Religious/cultural needs*

Do you require an interpreter?*

Ethnicity/Cultural Identity*

Primary Language*

Do You Identify As Aboriginal*

Do You Identify As Torres Strait Islander*

Medicare Details

Card Number

REF Number

Expiry Date

Concession Details

Concession card type

DVA Colour*

Card Number

Expiry Date

Next of Kin & Emergency Contact

Next of kin Name*

Phone*

Relationship*

Emergency contact Name*

Phone*

Relationship*

Children under 16

Children under 16 need to have an adult as the primary account holder (appearing on the same Medicare card) as Medicare will not accept claims for children.

Who is the legal guardian

Is the legal guardian a patient at this practice?

Please provide your details

Full Name*

Date of Birth*

Medicare Number*

Ref Number*

Expiry Date*

Privacy policy

I understand that View Street Medical complies with the Privacy Act (1988) and the Australian Privacy Principles (APP). As part of their Privacy Policy they are committed to protecting the privacy of individuals and their personal information. The purpose of collecting my personal information is to provide quality medical and health related services and associated business processes (eg. financial claims and payments, practice audits and accreditation). I understand that the staff and doctors at View Street Medical make every effort to manage my information in accordance with the Australian Privacy Policy Principles and keep my records accurate and up to date. I understand that I may withdraw my consent for View Street Medical to use and disclose my personal information except when legal obligations must be met. This practice uses a recall and reminder system to enable a systematic approach to health promotion and preventative care. My signature below indicates that I have read the above and consent to the following: • View Street Medical collecting, using and storing of my personal information for the purposes of medical and health related services and associated business processes • The release of relevant personal information to other health professionals to allow quality medical care (eg. medical specialists) • The release of relevant personal information to employer/prospective employer, their authorised representative and their insurer in case of a work-related consultation or service with my informed consent • Inclusion in a recall register to be advised of follow-up visits, medical updates and health information A copy of our Privacy Policy is available on request.

I confirm my understanding and consent to the above collection, storage and use of my medical records*

Confirm

NON-ATTENDANCE FEES

View Street Medical will issue an account fee to the equivalent of the cost of the consultation missed. This is where a person fails to attend an appointment on more than one occasion or provides less than 2 hours’ notice for cancellation. Failing to provide notice of cancellation or not attending an appointment reduces the availability of appointments for other patients.

SMS CONSENT

Do you consent to receive SMS communications for appointment reminders, clinical reminders and recalls, and other health awareness reasons?*

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08 9227 0170

14-16 View Street

Patient Registration Form