New Patient Registration

New Patient Registration Form

In order to be able to provide you with the best quality of care, we need accurate information. Our practice follows the guidelines of The Royal Australian College of General Practitioners handbook for the management of health information in private medical practice. This means that your personal health information is kept private and secure, as required by federal and state privacy laws.
Patient Name*
Prefix Given name Family name
Preferred Name
Ethnicity*
- A.T.S.I.
- European
- Asian
- African
- Other
Date of Birth*
DD slash MM slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mobile Phone No.*
Home Phone No.
Business Phone No.
Medicare No.
Position Number
eg. 2
Expiry Date
DD slash MM slash YYYY
Do you have a pension or repatriation number?*
- Yes
- No
Pension/Repat No.*
Expiry Date*
DD slash MM slash YYYY
Do you have a health care card?*
- Yes
- No
Health Care Card No.*
Expiry Date*
DD slash MM slash YYYY
Do you have a private health fund?*
- Yes
- No
Name of Fund*
What level of cover do you have?*
- Gold
- Silver
- Bronze
Occupation
Employer
Work Phone No.
Responsible Person
Is this patient responsible for themselves?*
- Yes
- No
Name of responsible person*
Prefix Given name Family name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Ph.*
Mobile Ph.*
Relationship to Patient*
Is there a second person responsible for the patient?*
- Yes
- No
Name of responsible person 2*
Prefix Given name Family name
Person 2 Home Ph.*
Person 2 Mobile Ph.*
Person 2 Relationship to Patient*
Emergency Contacts
Please list two people who could be notified in case of an emergency (not living at home with the patient).
Contact 1 Name*
Prefix Given name Family name
Contact 1 Phone No. (Home)*
Contact 1 Phone No. (Mobile)*
Contact 1 Relationship to Patient*
Is this contact your next of kin?*
- Yes
- No
Contact 2 Name*
Prefix Given name Family name
Phone No. (Home)*
Contact 2 Phone No. (Mobile)*
Contact 2 Relationship to Patient*
Is this contact your next of kin?*
- Yes
- No
Next of Kin
You have indicated that neither of the above emergency contacts is your next of kin. Please indicate your next of kin below in case they also need to be contacted.
Name*
Prefix Given name Family name
Relationship to Patient*
Contact Phone Number*
How did you hear about our practice?*
- Family/Friends
- Signage
- Local paper
- Internet
- Mail out
- Yellow Pages
- Specialist
- Chemist
- Other
Which specialist?*
Which chemist?*
Please specify*
General Health Information
Our main focus is to provide the best medical care available. Your lifestyle, ethnic origin, health problems that you may have, and medications that you may be taking -- including OTC, vitamins, and holistic / herbal preparations -- can have an important inter-relationship with your general state of health and future management. For these reasons, we ask that you kindly answer the following questions. (Your answers are for our records only and are confidential).
Do you smoke?
- Yes
- No
How many?*
Do you drink alcohol?
- Yes
- No
Have you suffered any serious illness or had operations in the past?
- Yes
- No
Please specify*
Do you have a history of any of the following?
- High blood pressure
- Stroke
- Blood clots/thrombosis
- Diabetes
- Cancer
- Heart trouble
- Emphysema or chronic bronchitis
- Epilepsy
- Kidney disease
- Hepatitis/HIV
- Bleeding tendency
- Other lung disease
- Depression/anxiety
Please check all that apply.
Do you currently have any of the following?*
- Cold
- Cough
- Shortness of breath
- Fever
- Sore throat
- Headache
- None of the above
Please check all that apply
Have you had contact with anyone who has Coronavirus (COVID-19) or influenza?*
- Yes
- No
Are you currently taking any medications?
- Yes
- No
Please specify*
Do you have allergies to any medications or medical tape?
- Yes
- No
Please specify*
Do you have any other (general) allergies?
- Yes
- No
eg. foods, beestings, etc.
Please specify*
Patients, please note:
Patients are advised that The Clinic 279 is a Private General Practice and currently bills patients at fees that reflect the AMA recommended fees. The AMA recommends fees based on what is fair and reasonable, but patients are reminded that these are beyond the standard rebate provided by Medicare. A standard consultation takes up to 10-15 minutes. Consultations longer than 20 minutes attract a higher fee and a higher Medicare rebate. A full list of fees is available for your perusal on request. Rising costs including medical indemnity costs necessitate increases in fees from time to time. The terms of contract are settlement of all consultation accounts on the same day. Please note that cancellations of appointments require 24 hours notice. For children 16 years and younger, DVA patients and Holders of Current Pensions and Health Care Cards, this practice will accept the Medicare Rebate via bulk-billing as full payment of the fees. This represents around a 50% discount on the AMA recommended fee. This may be subject to change without notice.
If you do not have a current Centrelink card, how would you prefer to settle your account?*
- Cash
- Credit card
- Cheque
- EFTPOS
- I have a current Centrelink card
Patient Privacy Information
To provide a high standard of medical care we need to collect personal information from our patients. This information is usually collected from the patient but may be collected from family members and other health care provider’s with the patient’s consent. At times some of this information needs to be shared with other health care providers or we may be legally bound to disclose personal information. All persons accessing your personal health information are bound by confidentiality. Please do not hesitate to discuss any concerns, questions or complaints about any issues related to the privacy of your personal information with your Doctor.
Signed by Patient
I understand and agree to the terms stated and confirm the above information to be true & accurate.
Signature*

ABOUT US

The doctors, nurses and support staff at The Clinic 279 have one clear goal: to provide high quality care to individuals and families.

Book Online

EMERGENCY

For all emergency cases, do NOT use any contact forms on this site. Please dial 000 immediately.

CONTACT INFO

ADDRESS

279 Gilbert Rd, Preston VIC 3072

PHONE

(03) 9470 1954

FAX

03 9471 0558

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New Patient Registration

New Patient Registration Form

Responsible Person

Emergency Contacts

Next of Kin

General Health Information

Patients, please note:

Patient Privacy Information

Signed by Patient

ABOUT US

EMERGENCY

CONTACT INFO

ADDRESS

PHONE

FAX