New Patient Registration Form
Please complete all sections accurately. Your information is strictly confidential and protected in accordance with the Privacy Act.
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Title: Dr / Mr / Mrs / Ms/ Miss/ Other  *
First Name : *
Surname : *
Date of Birth (DD/MM/YYYY) *
Residential Address  (House No./ Street/Suburb/State/Postcode) *
Contact Number (Mobile) *
Medicare Card No.
Medicare Card Ref No.
Medicare Card Expiry (MM/YY) *
DVA Card Number & Card Type (Gold or White)
Pension/Concession Card No. and Expiry (month/year)
Private Health Fund Name & Member No.
Do you identify as Aboriginal or Torres Strait Islander? *
Emergency Contact & Next to Kin 
Full Name :
 *
Emergency Contact & Next to Kin
Relationship to You :
 *
Emergency Contact & Next to Kin
Contact No :
 *
6. Brief Medical History *
If Yes, please list allergy and reaction : 
Current Regular Medications:  *
Smoking History *
Alcohol Consumption *
Diabetes 
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High Blood Pressure
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Patient Consent & Privacy Agreement

Please read and sign below to consent to our practice policies.

1. Privacy & Health Information: I consent to this practice collecting, using, and disclosing my personal health information to provide comprehensive healthcare, including sharing relevant details with specialists or hospitals if referred.

2. Communication: I consent to receiving appointment reminders, clinical recalls, and health notifications via SMS or email.

3. Fees & Billing: All eligible patients who have a Medicare Card, Pension Card and children under16 will be bulk billed. I acknowledge that I am responsible for paying any practice fees on the day of my consultation, including any gap payments not covered by Medicare.

All missed appointments without adequate notice ( 2 hours minimum) will incur a no-refundable $30 fee which must be paid prior to booking another appointment.
Patient Signature (Your Name) *
Patient Signature (Date)
MM
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DD
/
YYYY
Parent or Guardian to sign if patient is under 16 years of age (Your Name) *
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