New Patients – Toombul Medical Centre

New Patient Form

Please fill out the patient form below to get you started. If there is a technical issue please let our receptionist know.

Book an Appointment

PLEASE COMPLETE THE FOLLOWING INFORMATION

Privacy: In accordance with the New Federal Privacy Laws, the answer to the questions below are used for data entry, audit and administration purposes in communication with other Health Professionals, and are kept with your medical record.

CONSENT TO TREATMENT - I agree to provide the following information

Your Title:

Given First Name:

Family Name:

Preferred Name:

Height:

Weight:

Waist Measurement:

List ANY Allergies:

Do You Self Identify with any Cultural Background

Aboriginal

Torres Strait Islander:

Other:

Contact Details (Leave blank if not applicable)

Address:

Suburb:

Postcode:

Home Telephone:

Work Telephone:

Mobile Telephone:

Email Address:

Occupation:

Birth Country:

Year Arrived Australia:

Other Languages Spoken:

Interpreter Required:

Next of Kin

Name:

Relationship:

Home Telephone:

Mobile Telephone:

Emergency Contact

Name:

Relationship:

Home Telephone:

Mobile Telephone:

I consent to & acknowledge the following (PLEASE TICK)

* My alternative emergency contact or next of kin can be contacted in the case of an emergency or if we are unable to contact you on your given telephone numbers or given address. IMPORTANT – Please advise us if you change your address or telephone number.

* I Authorise Toombul Medical Centre to upload a Health Summary to My Health Record

* I understand that all Bulk Billing Appointments are strictly ONE issue per consultation

* Date:

Health Care Card Details

Medicare Card Number:

Ref:

EXP:

Pension Card Number:

EXP:

Health Care Card Number:

DVA:

Family History – Tobacco

Tobacco: I have never smoked

Tobacco: I Ceased Smoking on

I smoke:

Family History – Alcohol

Alcohol: I do not drink Alcohol

I drink:

How often would you drink more than 6 standard drinks per day:

Recreational Drug Use:

Type and frequency:

New Patient Form

PLEASE COMPLETE THE FOLLOWING INFORMATION

Toombul Medical Centre

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