Patient Registration

Patient registration

Name*
First Middle Last
Male or Female
- Male
- Female
- Other
Date of birth*
dd/mm/yyyy
Marital status:
- Single
- Married
- Engaged
- Divorced
- De facto
- Have a partner
Address
Street Address Suburb Postcode
Phone home
Phone mobile*
Phone work
Email*
Medicare number:*
Expiry*
Number in front of name on medicare card:*
Pension healthcare card number:
Expiry
Centrelink Healthcare Card / Pension Card:
Expiry
Veteran’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
Occupation
Ethnicity:
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 language
Any special needs:
Any custody issues?
Medical History
Do you have any allergies to medicines or anything else?
- yes
- no
Please detail allergy and reaction type
Current medications (including over the counter medicine)
Please detail – medicine name / strength / times taken
Have you had any major operations, or been admitted to hospital?
Please detail year, operation and reason.
When was your last check for the following:
Cholesterol
Bowel cancer
Blood pressure
HIV test
Prostate check
Hepatitis test
Pap smear
Mammogram/breast screen
Social 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 Form
As 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
Signature
Your Name
Your Name
Your Name
Date
Are you a parent or guardian completing form?
- Yes
- No
Signed as guardian for child
Your Name
Your Name
Your Name
Name
First Last

Patient Registration

Patient registration

Emergency contact / Next of kin:

Medical History

When was your last check for the following:

Health Information Collection and Use Consent Form