New Patient Registration

Wednesday,February 22,2012

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New Patient Form

NEW PATIENT REGISTRATION ONLINE

In order to speed up your registration process upon your first visit, we would appreciate you filling in your details online.

It might seem like there are a lot of details, but all are vitally important for various reasons. Health_Online_-_Chermside_Medical_Centre

1) To enable us to open a file in our clinical software

2) To allow you to claim your medicare rebate

3) To allow us to contact your next of kin or emergency contact in the event of a serious medical event where you are unable to provide these details

4) To allow us to notify you of any abnormal results, some of which can be life threatening.

5) To allow us to communicate to you important health announcements.

NEW PATIENT REGISTRATION NEVER BEEN EASIER

We will hold all of your details in strict confidence and guarantee that your information

will not be passed on to any third parties.

Required *

Title *

Given Names *

Preferred Name

Surname *

Date of Birth *

Sex *

Marital Status *

Address *

Suburb *

State

Postcode

Postal Address if Different to Above

Home Phone *

Work Phone

Mobile *

SMS to this mobile?

Medicare Number *

Reference Number *

Medicare Card Expiry Date *

Dept. of Veteran Affairs Number

DVA Expiry Date

Pension/HCC Number

Pension/HCC Expiry Date

Next of Kin *

Relationship to Next of Kin *

Next of Kin Address *

Next of Kin Suburb *

Next of Kin Phone *

Next of Kin Mobile

Emergency Contact *

Occupation *

Employer (if work related injury)

Employer Address (if work related injury)

Employer Phone Number

Aboriginal of Torres Straight Islander *

Country of Birth

List Family Members and DOBs

How did you hear about us? *

Please write the letters that you see in the picture to verify that you are a human

You are not a human