Patient registration - Dr Suntharalingam Sivananthan

Name*

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 events

Smoking history:

Never
Former Smoker
Current Smoker

Quit date:

Current smoker - number per day:

Current smoker - year started:

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 Consent

Dr 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:*

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.