New Patient Registration - Hornsby Medical Practice

Title*

Name*

First Name Surname

Date Of Birth*

Address*

Street Address Suburb Post Code

Home Phone

Mobile Phone

Occupation

Work Phone

Medicare

DVA Gold
DVA White /Health Card/Pension No

Reference Number

Expiry

Emergency Contact

Relationship to Patient	Name	Phone

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
No

To assist with health initiatives – are you an Aboriginal or Torres Strait Islander?

No
Yes – Aboriginal
Yes - Torres Strait Islander

Ethnicity

Do you have any allergies or are you sensitive to drugs?

No
Yes

Please elaborate

Do you use any of the following:
(list amount where appropriate)

Alcohol

No
Yes
Standards per day

Days per week

Tobacco

No
Yes
Ex-smoker

Number per day

Year ceased

Have any members of your family had:

No Significant Family History

Diabetes

Mother
Father

Mental Illness /Depression

Mother
Father

Cancer

Mother
Father

Heart Disease

Mother
Father

Privacy 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)

Could you please assist us by completing the following: