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New Patient Registration
New Patient Information Form
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We are committed to providing our patients with the best care. To do this, it is essential that your health record contains complete and accurate information. Please assist us by completing your new patient record form:
Contact Information
Title
Name
First
Middle
Last
Birthday Sex
Gender Identity
Date of Birth
DD slash MM slash YYYY
Street Address
Postal Address
Home Phone:
Mobile Phone
Email
Marital Status
Occupation
Consent to SMS
Yes
No
Healthcare Identifiers
Medicare Number
Ref
Expiry
Concession Pension Card Number
Expiry
Concession Health Care Card Number
Expiry
Dept. of Veterans’ Affairs File Number:
Select one
Gold
White
Private Health Insurance Name
No #
Cultural Identity
Country of Birth
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
To assist with health initiatives - are you Aboriginal and/or Torres Strait Islander?
No
Yes – Aboriginal
Yes - Torres Strait Islander
Yes - Aboriginal / Torres Strait Islander
As Australia is a genuinely multicultural society, and to tailor appropriate care, encourage understanding and appreciation between people from different nationalities and cultures - do you identify as someone from a culturally and/or linguistic diverse background?
No
Yes
Please elaborate
Do you require an interpreter service?
No
Yes
Next of Kin
Name
Relationship to you
Home Phone
Mobile Phone
Emergency Contact Details
Name
Relationship to you
Home Phone
Mobile Phone
Head of Family for the Medicare Rebate
Name
Relationship to Patient
How did you find out about WAMC
How did you find out about WAMC
Friend / Relative / Internet / Driving past / Newspaper / Other
Why did you choose us?
Your Health Information
Name
Date of Birth
DD slash MM slash YYYY
ALLERGY INFORMATION - Do you have any allergies or are you sensitive to drugs or dressings?
No
Yes – provide details
Allergy Information
Provide details
CURRENT MEDICATIONS
Please list all your current medications, including complementary and overthe-counter medicines (e.g. homeopathic medicines such as vitamins and minerals etc.)
MEDICAL HISTORY - Do you have or have you had a history of the following?
Asthma
Hypertension
Diabetes
Chronic Illness
Surgery
Other
Medical History
Provide details
HAVE YOU HAD ANY VACCINATIONS?
No
Yes – provide details
Allergy Information
Provide details
LIFESTYLE RISK FACTOR INFORMATION
Smoking
Non Smoker
Ex Smoker
Smoker
Cigarettes per day
Year Started
Recreational Drug Use
No
Yes
Type
Frequency
Current Alcohol Intake
Non Drinker OR
days per week
standard drinks per day
Description
Family Health History Information
Do any members of your family have:
Heart Disease
Diabetes
Mental Illness
Asthma
Hypertension (high blood pressure)
Cancer
Other significant
Cancer Type
Provide details
Medical Power of Attorney / Medical Decision Maker / Financial Power of Attorney
Medical Power of Attorney / Medical Decision Maker / Financial Power of Attorney
Yes
No
If yes please attach paperwork or provide at a later date
Do you have any Specialist doctors or Allied Health professionals who provide care to you?
Do you have any Specialist doctors or Allied Health professionals who provide care to you?
Yes
No
If yes please provide name/s:
Names of Specialist doctors or Allied Health Professionals
Reminders and Privacy
Our practice uses a reminder system for health and preventative care. We may send you reminders by post, telephone or SMS. This practice operates in accordance with the Australian Privacy Principles. We will treat your information as private and confidential. We will only disclose it for purposes directly related to your health care. There are circumstances where we may be required or permitted to disclose your information to 3rd parties, e.g. to Medicare, Police, courts of law, hospitals or debt collection agencies. The practice has a comprehensive privacy policy, available at Reception and our website.
Reminders and Privacy
I have read and understand the information provided and agree to be contacted for Reminders and for my information to be shared for my healthcare purposes
Booking Appointments and Cancellation Policy
We require all patients to attend for a consultation with their GP for all health needs, including results, referrals and prescriptions.
We have appointments for 10 minutes, 20 minutes and longer in some circumstances. It is very helpful in managing the flow of appointments for patients to book appointments according to the complexity of their health issues and the time required. We strive to keep to our appointment times and would request that patients arrive on time for appointments. If unexpected delay is known, please contact Reception before the appointment time. If you cannot make your scheduled appointment we ask that you contact the practice as early as possible, so we can allocate the appointment to another patient. Failure to provide more than 4 hours’ notice may incur a cancellation fee.
Please do not notify our practice via email.
Booking Appointments and Cancellation Policy
I have read and understand the Booking Appointments and Cancellation Policy
Terms and Conditions
WAMC is a private billing clinic, fees are payable on the day of consultation, we accept cash, credit or EFTPOS cards. If an account is not paid on the day of consultation a $10 account keeping fee will be incurred. In the event that a Work Cover or TAC claims are rejected, the patient accepts full liability for these accounts. There are some consultations where the Medicare fee is not claimable. If an overdue account is referred to a collection agency or solicitors, the patient will be liable for all legal costs and commission arising.
Saturday mornings incur a $10 surcharge.
Terms and Conditions
I have read and understand the Terms and Conditions policy and agree to pay my account at the time of consultation
Third Party Consent
Our practice is a teaching venue and there may be times when students are onsite to complete clinical placement. Your written consent will be requested and recorded prior to the consultation, if you agree. If you request to have a 3
rd
party present in a consultation, your verbal request/consent will be noted in your health record.
Third Party Consent[
I have read and understand that I have the right to request or deny a 3
rd
party presence
Patient name: (please print)
DOB
DD slash MM slash YYYY
Signature
Date
DD slash MM slash YYYY
If not patient signing - your name (please print)
Your relationship to patient (e.g. Mother, Father, guardian):
New Patient Registration
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