Patient Registration Patient registration Name* First Middle Last Male or Female Male Female Other Date of birth*dd/mm/yyyyMarital status: Single Married Engaged Divorced De facto Have a partner Address Street Address Suburb Postcode Phone homePhone mobile*Phone workEmail*Medicare number:*Expiry*Number in front of name on medicare card:*Pension healthcare card number:ExpiryCentrelink Healthcare Card / Pension Card:ExpiryVeteran’s number:We regularly send SMS reminders, recall letters and reminder letters. If you DO NOT wish to receive please indicate below Do not SMS reminders etc OccupationEthnicity:Are you Aboriginal/ Torres Strait Islander? Yes No Emergency contact / Next of kin:Name* First Last Relationship:Address Street Address Suburb Post code Phone / Mobile:*Preferred languageAny special needs:Any custody issues?Medical HistoryDo you have any allergies to medicines or anything else? yes no Please detail allergy and reaction typeCurrent medications (including over the counter medicine)Please detail – medicine name / strength / times takenHave you had any major operations, or been admitted to hospital?Please detail year, operation and reason. When was your last check for the following:CholesterolBowel cancerBlood pressureHIV testProstate checkHepatitis testPap smearMammogram/breast screenSocial history: Cigarette Alcohol Intravenous drugs Exercise Significant family history:Have you ever had: Heart Problems Angina High blood pressure High cholesterol Serious infection Skin rashes, dermatitis, eczema, psoriasis Epilepsy/fits/blackouts/ strokes Migraine Varicose veins, clots or blocked arteries Asthma/emphysema breathing Gastro-intestinal: liver disease/ stomach ulcers/gallstones/ pancreatitis/hepatitis/ jaundice Back/neck problems/muscles/joint pain/arthritis Hernia/ bowel problems/rectal bleeding Emotional disorder/ stress Diabetes Kidney/urine/bladder problems/prostrate problems/ impotence Thyroid: endocrine/hormone problems Abnormal pap smear Gout Sexually transmitted disease/AIDS Serious trauma Intravenous drug use Cancer-where? Eye/ear problems Hay fever/sinus problems Other Health Information Collection and Use Consent FormAs a patient of Glen Iris Medical Centre we require you to provide us with your personal &demographic details and a full medical history, so that we may properly assess, diagnose, treat and be proactive in your health care needs. Personal information may also be collected from the patients guardian or responsible person (where practicable and necessary), or from any other involved healthcare specialists. We aim to protect the privacy and secure storage of your health information. You can request a copy of our privacy policy, which includes information about the collection, use and disclosure of your health information. We require your consent to collect personal information about you and to use the information you provide in the following ways. Please read this consent form carefully, and sign where indicated below. Administrative purposes in running our medical practice. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.Some disclosure may occur to third parties engaged by or for the Practice for business purposes, such as accreditation or for the provision of information technology. These third parties are required to comply with this policy. The Practice will inform the patient where there is a statutory requirement to disclose certain personal information (for example, some diseases require mandatory notification). The Practice will not disclose personal information to any third party other than in the course of providing medical services, without full disclosure to the patient or the recipient, the reason for the information transfer and full consent from the patient. The Practice will not disclose personal information to anyone outside Australia without need and without patient consent. Exceptions to disclosure without patient consent are where the information is: Required by law Necessary to lessen or prevent a serious threat to patients life, health or safety or public health or safety, or it is impractical to obtain the patients consent To assist in locating a missing person To establish, exercise or defend an equitable claim For the purpose of a confidential dispute resolution process. For reminder letters which may be sent to you regarding your health care and management. You can decline to have your health information used in all or some of the ways outlined above but it may influence our ability to manage your health care to provide the best outcome for you. Consent I understand that I am not obliged to provide any information requested of me, but failure to do so may compromise the quality of health care and treatment given to me. I am aware of my rights to access the information collected about me, except in some circumstances where access may be legitimately withheld. 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 the practice for the purpose set out above, subject to any limitations on access or disclosure of which I notify this practice. Or: I am unsure and would like to discuss this further with someone from the medical practice before I sign. Patient Name First Last SignatureDate DD slash MM slash YYYY Are you a parent or guardian completing form? Yes No Signed as guardian for childName First Last