New patient registration form

Select Drs.

Drs. Name
Dr. Asrar Khan (Consultant Nephroligist) Dr. Saima Paracha (Consultant General Medicine)

Section A: Personal details

Title

Surname

Given names

Date of birth (dd/mm/yy)

Gender

Marital status
Single Married Defacto Separated Divorced Widowed

Medicare card number

Medicare reference number

Medicare card expiry date

Pension, Health Care Card, or Veterans Affairs number (if applicable)

Type of Veterans Affairs card

Expiry date

Occupation

Home address

Postcode

Postal address

Postcode

Telephone number

Work number

Mobile number

Who can we contact in an emergency (Next of kin)?

Name

Relationship to you

Telephone number

Work number

Mobile number

Do you have an advance health directive for end of life care?
Yes No

For more information talk to your GP.

Section B: Cultural background

Knowing your cultural background can help us provide healthcare that meets your individual needs

Are you of Aboriginal or Torres Strait Islander origin?
No Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander

Other cultural background (eg Mediterranean, Asian, African)

Country of birth

Is English Your First Language
Yes No

If not, do you require an interpreter?
Yes No

Please specify language

Section C: Allergies and medicines

List allergies and intolerances to medications

Describe your reaction

List regular medications and doses, and complementary medicines and doses

Section D: Consent

Our practice uses a reminder system to help you maintain your health.The practice sends reminders by post, email, telephone or SMS for procedures such as vaccinations, Pap tests and other health reviews.

I consent to being contacted with reminders to help me maintain my health
Yes No

Our practice also sends information to the Australian Childhood Immunisation Register and Pap Smear Register. These registers also send reminders, which can be helpful if you move.

I consent to being contacted with reminders to help me maintain my health
Yes No

Signature

Date

Section E: Transfer of health information

You may have consistently consulted with a GP at another practice. The health information held by that GP may assist us with your future healthcare needs. You may wish to have a copy or a summary of your health records transferred to this practice. Please ask the receptionist for information about how this can take place.

Please advise us if your contact information or Medicare details change.

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