Registration Form - Carnegie Family Clinic

New Patient Registration Form

165-167 Koornang Rd, Carnegie, VIC 3163

Ph: 03 90700288

Fax: 03 99598376

Email: reception@carnegiefamilyclinic.com.au

TitleMrMrsMsMissMSTROther

First Name*

Middle Name

Surname*

Preferred Name

Address*

Suburb*

Postcode

Date of Birth*

GenderMaleFemaleOther

Phone Contact

Home

Mobile*

Work

Email*

Are you of Aboriginal or Torres Strait Islander Descent?YesNo

AboriginalTorres Strait Islander

Medicare Number

Ref. No.

Expiry Date

ConcessionsHealth Care CardPensionDVA GoldDVA White

Entitlement Number

Expiry Date

Culture Background

Country of Birth

Language Spoken

Ethnicity

Do you need an interpreterYesNo

Marital Status*MarriedDe FactoSingleWidowedDivorcedSeparated

Occupation*

Weight(kg)*

Height(cm)*

Emergency Contact Details

Name*

Relationship

Mobile*

Phone Number

Next of KinTick if the same as above

Name

Relationship

Mobile

Phone Number

Basic Health Information

Do you drink Alcohol?*NoYes

Days per week

Number per day

Smoker?*NeverEx-SmokerYes

If you are ex-smoker, since when?

If Yes, number per day?

Medical History

Do you have any Allergies? (Medication/Antibiotics, Adhesives, Food etc)

Please list your current medications: eg. Warfarin, Aspirin, Steroids

Please list any current medical conditions: eg. Asthma, Diabetes, Heart Conditions, Pacemaker

Family History of Heart Disease, Diabetes, Cancer, or any other Disease? If yes please give details

Social History (Like Hobbies, Physical/Social activities etc)

SMS Result Notification & Reminder System

Do you wish to receive notification of your clinically significant results and reminders by SMS?NoYes

If we need to contact you what is your Preferred method of contact?SMSMobileMailHome Phone

Consent for “My Health Record”
Your doctor can upload your basic health summary to your “my health records” profile so that it can be accessed by health professionals in Australia.

Do you give consent for it?NoYes

HEALTH INFORMATION COLLECTION AND USE

I consent that this general practice, Carnegie Family Clinic, collects information from me for the primary purpose of providing quality health care. It is the policy of this practice to maintain security of personal health information at all times and ensuring the information is only accessed by authorized members of staff and other health professionals if needed for benefit of my health. I am required to provide them with my personal details and a full medical history so that they may properly assess, diagnose and treat illnesses and medical conditions, ensuring they are proactive in my health care. To enable ongoing care, and in keeping with the Privacy Act 1988 and Australian Privacy Principles, Carnegie Family Clinic wish to provide me with sufficient information on how my personal information may be used or disclosed; they will record my consent or restrictions to this consent. My personal information will only be used for the purposes for which it was collected or as otherwise permitted by law, and my right to determine how my information is used or disclosed is respected. I consent to de-identified data (including, without limitation, photographs of my skin and any cancers) being used for medical training and medical research by Carnegie Family Clinic and such data being provided to third parties for these same purposes.

FINANCIAL CONSENT: I agree that above is a true and accurate record. I understand that Carnegie Family Clinic requires payment on the day of treatment. Any Expense or costs incurred by Carnegie Family Clinic is recovering outstanding monies including debt collection fees will be paid by the parties above. I also further Acknowledge that failure to attend an appointment without notice may result in a deposit requirement before future appointment will be made and a fee charged for the cancelled appointment. Medicare care Holders: I approve to assign my right to a Medicare benefit to Carnegie Family Clinic for the services provided to me.

I have read understood the information provided above and give consent for my personal information being using in the ways listed above.*

Signature*