Patient registration Name* Mr.Mrs.Ms.MissDr. Prefix Surname First name D.O.B Email* Address Street Address Suburb Post Code Home phone: Mobile phone: Work phone: Emergency contact name: First Last Emergency contact relationship: Emergency contact phone: Next of kin name: First Last Next of kin relationship: Next of kin phone: Preferred method of communication: Mobile phone Home phone Mail Email Your Cultural Identity: Aboriginal Torres Strait Islander Other Other cultural identity: Medicare no: Reference no: Expiry date: Pension/Healthcare Card No: Expiry date: Private Health Fund Name: Private Health Fund Membership Number: Do you have a DVA GOLD or WHITE Card? Yes No DVA Number: Card colour: Gold White Orange Please list any allergies & types of reactions:Please list current medications:Past Medical History:Please include year of relevant eventsSmoking history: Never Former Smoker Current Smoker Quit date: Number of cigarettes per day: Year started smoking: Alcohol: Non-drinker Drinker How many days per week: Glasses per day: Occupation: Family history Diabetes: Mother Father Sister/Brother Grandparents Family history Heart Disease: Mother Father Sister/Brother Grandparents Family history Stroke: Mother Father Sister/Brother Grandparents Family history Asthma: Mother Father Sister/Brother Grandparents Family history Cancer: Mother Father Sister/Brother Grandparents Patient ConsentDr Sivananthan collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways. Administrative purposes in running our medical practice. Billing purposes, including compliance with Medicare Australia requirements. To contact you or your family for the purpose of Recalls and Reminders. Disclose to others involved in your health care, including treating doctors and specialist’s outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports and results returned to us following the referrals. I have read the information above and understand the reasons why my information is collected. I understand that I am not obliged to provide information requested of me, but that my failure to do so might compromise the quality of health care and treatment given to me. I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand 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 put above, my further consent will be obtained. I consent to the handling of my information by this practice for the purpose set out above. Patient Consent/Acknowledgement I agree and acknowledge that photos may be taken for clinical management and data could be used for audit purposes. I agree that photos and clinical information may be transmitted/transferred electronically. Signature*Patient name:* Date:* MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.
