New Patient Details Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Preferred NameAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth(Required) DD slash MM slash YYYY Email(Required) OccupationINDIGENOUS(Required) Yes No N/A Aboriginal Torres Strait Islander Both Phone (Home)Phone (Work)MobileNext of KinRelationshipPhoneMedicare NumberRef # (Next to your name)Expiry DD slash MM slash YYYY Do you have private health insurance (hospital cover)?(Required) Yes No Fund NameMembership NumberDo you have a Veteran’s Affairs Gold Card?(Required) Yes No Do you receive the AGE pension?(Required) Yes No Pension Type(Required) FULL PART GP/Local Drs NameSuburbOptometristSuburbBilling(Required) I understand that this is not a bulk billing clinic and I am responsible for the full payment of my account at the end of my consultation or procedure.PRIVACY INFORMATION AND CONSENT FORM We value the doctor-patient relationship and patient privacy is vital to such a relationship. We have a legal right and ethical duty to protect patient information. The law gives you certain privacy rights in relation to information that you give to this medical practice. We require your consent to collect personal information about you. By attending this practice you give consent to our doctors and staff knowing about your health situation. We collect information to aid in assessing, diagnosing and treating your condition appropriately, liaise with other doctors and health professionals and to enable us to be proactive in your health care. We also use the information you provide in the following ways: Administration within this medical practice Billing, including compliance with Medicare and Health Insurance Commission requirements Patients who wish to look at their information held within this practice or who have queries about privacy of information are welcome to discuss these matters with their treating doctor.Patient's Acknowledgement(Required) I have read this form and understand why collecting information about me is necessary. I am also aware that this practice has a privacy policy on handling patient information. I authorise the collection and disclosure of information to my GP or any other health care provider or institution involved in my care and also to appropriate bodies in relation to quality assessments and quality assurance, clinical auditing and research to improve individual and community health care and practice managementSigned (Patient)(Required)CommentsThis field is for validation purposes and should be left unchanged.
