New Patient Registration | Medika Health Clinic

New Patient Registration

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Patient Details

Title:

Surname:

Given Names:

DOB:

Pronouns:

He:Him

She:Her

Them:They

Birth Sex:

M

F

Address:

Gender:

Male

Female

Other

Suburb:

Post code:

Marital Status:

Phone:

Home

Phone:

Work

Mobile:

Email:*

Medicare, Centrelink & Veteran's Affairs

Medicare No:

Line No:

Expiry:

Centrelink CRN:

Health Care Card/Pension Card

Health Care Card

Pension Card

Expiry:

Veteran's Affairs:

Colour:

Expiry:

Emergency Contact Persons

Next of Kin:

Relationship:

Phone:

Home / Work

Mobile:

Emergency Contact:

Relationship:

Phone:

Home / Work

Mobile:

Cultural Background

Are you of Aboriginal or Torres Strait Island descent?

Aboriginal

Torres Strait

Both

Do you identify as someone from a culturally and/or linguistically diverse background?

Yes

No

If yes, please specify culture/nationality:

Do you require interpreter assistance?

Yes

No

Native Language:

Consent

Medika Health Clinic uses a reminder system to help you maintain your health. The Practice sends reminders via post, email, telephone and/or SMS for things such as vaccinations, pap tests and other health reviews.

If you would be more comfortable providing the above information to your GP directly, please provide this information to them during your consultation. Our Practice also sends information to the Australian Immunisation Register, and Pap Smear and Cancer Registers. These registers also send reminders, which can be helpful if you move address.

Do you consent to SMS appointment reminders?

Yes

No

Do you consent to uploading records to your My Health Record?

Yes

No

General Health

Do you smoke?

No, I've never smoked

No, I quit _____ years ago

Yes, _____ per day

_____ years ago

_____ per day

Do you drink alcohol?

No, I never drink

Yes, I consume _____ drinks per day, _____ days a week

_____ drinks per day

_____ days a week

Height:

Weight:

Occupation:

If you would be more comfortable providing the above information to your GP directly, please provide this information to them during your consultation.

Family History

This risk assessment focuses on your close relatives including parents, children, brothers and sisters who are either living or dead.

Yes

No

Have any of your close relatives had heart disease before 60 years of age? Heart disease' includes cardiovascular disease, heart attack, angina & bypass surgery.

Yes

No

Have any of your close relatives had diabetes? Diabetes' is also known as type 2 diabetes or non-insulin dependent diabetes.

Yes

No

Do you have any close relatives who have/had melanoma?

Yes

No

Have any of your close relatives had bowel cancer before 55 years of age?

Yes

No

Do you have more than one relative on the same side of the family who had bowel cancer at any age? Please think about your parents, children, brothers, sisters, grandparents, aunts, uncles, neices, nephews, and grandchilren.

Yes

No

Have any of your close male relatives had prostate cancer before 60 years of age?

Yes

No

Have any of your close female relatives had ovarian cancer?

Yes

No

Have any of your close relatives had breast cancer before 50 years of age?

Yes

No

Do you have more than one relative on the same side of your family who has had breast cancer at any age? Please think about your parents, children, brothers, sisters, grandparents, aunts, uncles, neices, nephews, and grandchilren.

Yes

No

Privacy Notice for Patients

I agree to the privacy policy.

To enable ongoing care and continuity of total quality improvement within this Practice, and in keping with the Privacy Act 1988 and National Privacy Principles, we wish to provide you with sufficient information on how your personal health information and Medical Records may be used or disclosed to a third party and allow you the opportunity to either consent or deny release of your details.

Your personal health information and medical Records will only be used for the purpose for which they were collected, or as otherwise permitted by law. We respect your right to determine how your personal health information and Medical Records are used and/or disclosed.

This information we collect may be collected by several different methods, such as medical tests, consultation notes, Medicare and health insurance details, data collected, observations, and conversations with you and details obtained from other health professionals, i.e., specialist correspondence.

This Practice adheres to the principles of the Royal Australian College of General Practitioners (RACGP) Handbook (Fifth Edition) for the management of Health Information in private Medical Practice and has a written 'Privacy Policy' which is available to all patients on request.

I hereby consent to the use and disclosure of my personal health information and Medical Records, as required by Medika Health Clinic, for the following purposes:

· Providing pertinent information to other treating doctors, specialists, or allied health professionals
· Follow-up reminder/recall notices by mail, email and/or telephone
· National or State registers (i.e., Immunisation data)
· State or Territory reminder systems (i.e., Cervical screenings)
· Accounting, Medicare and health Insurance procedures and collection of professional fees
· Quality Assurance activites, such as Accreditation
· Disease notification as required by law (i.e., Infectious deseases)
· Use by all doctors, nurses and allied health professionals when consulting with you in this Practice
· Lawful disclosures as required by law (i.e., subpoenaed documents), and
· For research purposes (anonymised).

If I have concerns or wish to restrict access to my personal health information, I will discuss this with my doctor.

Patient Name

Guardian Name (for under 16 yrs)

Date

Signature

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Holistic wellbeing
Long-term healthcare
Patient-centred care
Education & prevention
Medicare rebates
Holistic wellbeing
Long-term healthcare
Patient-centred care
Education & prevention
Medicare rebates