New Patient RegistrationCould you please assist us by completing the following:Title*DrMrMrsMsMissName* First Name Surname Date Of Birth* Date Format: DD slash MM slash YYYY Address* Street Address Suburb Post Code Home PhoneMobile PhoneOccupationWork PhoneMedicareDVA GoldDVA White /Health Card/Pension NoReference NumberExpiry Date Format: 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?YesNoTo assist with health initiatives – are you an Aboriginal or Torres Strait Islander?NoYes – AboriginalYes - Torres Strait IslanderEthnicityChineseAmericanPakistaniLebaneseIranianIraqiEnglishWelshDo you have any allergies or are you sensitive to drugs?NoYesPlease elaborateDo you use any of the following: (list amount where appropriate)AlcoholNoYesStandards per dayDays per weekTobaccoNoYesEx-smokerNumber per dayYear ceasedHave any members of your family had: No Significant Family HistoryDiabetes Mother FatherMental Illness /Depression Mother FatherCancer Mother FatherHeart Disease Mother Father 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.
