New Patient RegistrationCould you please assist us by completing the following:Title*DrMrMrsMsMissName* First Name Surname GenderDate Of Birth* DD slash MM slash YYYY Address* Street Address Suburb Post Code Home PhoneMobile PhoneOccupationWork PhoneMedicare NumberMedicare DVA Gold DVA White /Health Card/Pension NoReference NumberExpiry DD slash MM slash YYYY Emergency ContactRelationship to PatientNamePhone Reminder Systems Our practice provides our patients with preventive care and early case detection reminders e.g. immunisations, annual health checks, skin checks and pap smears.Do you wish to have any relevant health reminders sent to you? Yes NoTo assist with health initiatives – are you an Aboriginal or Torres Strait Islander? No Yes – Aboriginal Yes - Torres Strait IslanderEthnicityChineseAmericanPakistaniLebaneseIranianIraqiEnglishWelshAustralianOtherDo you have any allergies or are you sensitive to drugs? No YesPlease elaborateDo you use any of the following: (list amount where appropriate)Alcohol No Yes Standards per dayDays per weekTobacco No Yes Ex-smokerNumber per dayYear ceasedHave any members of your family had: No Significant Family HistoryDiabetes Mother FatherMental Illness /Depression Mother FatherCancer Mother FatherHeart Disease Mother FatherPrivacy and Consent Form* I consent to the use of my health information by Hornsby Medical Practice and other health providers involved in their medical treatment and health care. I offer to assign my rights to Medicare benefit payable to the doctors of Hornsby Medical Practice who will render the medical service.Privacy and Consent Form We require your consent to collect personal information about you. Please read this information carefully, and sign where indicated below. This medical practice 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 healthcare needs. This means we will use the information in the following ways: 1. Administrative purposes in running our medical practice 2. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements 3. Disclosure to others involved in your health care, including treating doctors and specialists outside this practice. This may occur through referral to other doctors, hospital attendances, or for medical tests and in the reports or results returned to us after laboratory tests and imaging. 4. For Auditing or Research purposes I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information. I understand that I am not obliged to provide any 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 may legitimately be withheld. I understand I will be given an explanation in these circumstances. I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice. I already have an e-health record Y / N (delete as applicable) I do / do not (delete as applicable) consent to the creation of an e-health record on my behalf so that key registered agencies such as hospitals can access important details such as allergies, medications and past medical diagnoses. Print Full Name …………………………… Signed ………………………………………………… Patient’s Name……………………………………… & relationship……………………………. (if signed by parent / guardian)Date MM slash DD slash YYYY UntitledFirst ChoiceSecond ChoiceThird Choice
