Patient Registration - The IV Clinic

Patient Details

Title*

Surname*

Given Name/s*

Date of Birth*

DD slash MM slash YYYY

Gender*

If other, please specify*

Marital Status*

Medicare No.*

Ref No.

Expiration Date

Pension, Health Care Card or DVA White/Gold Card No:

Expiration Date

Occupation

Employer

Home Address*

Postcode*

Postal Address*

Postcode*

Email*

Phone (Home)

Phone (Work)

Phone (Mobile)*

Next of Kin

Name*

Relationship to you*

Phone (Mobile)*

Phone (Home)

Phone (Work)

Emergency Contact

Name*

Relationship to you*

Phone (Mobile)*

Phone (Home)

Phone (Work)

Do you identify as someone from a culturally and/or linguistic diverse background?*

Yes

If yes, Please indicate ethnicity*

To assist with health initiatives - are you Aboriginal or Torres Strait Islander?*

Yes - Aboriginal

Yes - Torres Strait Islander

Yes - Aboriginal & Torres Strait Islander

Health Questionnaire

Allergy to medication or food?*

Yes

Unknown

If yes, Please specify*

Smoker Status*

Never Smoked

Ex-Smoker

Smoker

If Ex-Smoker, Please specify year quit

If Smoker, Please specify no per day

Alcohol Intake*

Nil

Yes

If yes, please choose standard drinks/per*

Day

Week

Month

No of drinks*

Recreational Drugs*

Yes

Regular Medications*

Nil

Yes

If yes, Please list below any medications and their doses if known – include over the counter medications and supplements*

Current/Previous Medical Conditions*

Nil

Yes

If yes, please tick any that apply*

Asthma

Diabetes Type 1/Type 2

Heart Attack (MI)

Stroke/CVA

Pacemaker

DVT

Emphysema

Depression and/or Anxiety

Cancer

HIV/AIDS

Hepatitis A / B / C

Epilepsy

Other

Please specify Cancer type

If other, please specify*

Family Medical History*

Nil

Yes

If yes, Please list below*

Relation to you (e.g., mother, grandfather, sibling)

Condition/s

Our practice undertakes research, professional development, and quality assurance/improvement activities to improve patient care. All people accessing personal health information for this purpose have signed a written confidentiality agreement.

I consent to my health record being reviewed and uploaded to My eHealth Record as a part of the quality improvement activities in this practice.*

Yes

I give permission for my personal information to be collected, used and disclosed as described in this practice policy. I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.*

Yes

Our practice uses a reminder system to improve the quality of your health care. The practice sends reminders by mail or telephone for procedures such as vaccinations, pap smears and other health reviews.*

Yes

I consent to being contacted with reminders by sms/phone/email*

Yes

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Phone

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New Patient Registration

New Patient Registration

Patient Details

Next of Kin

Emergency Contact

Health Questionnaire

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