It is essential that your health record contains complete and accurate information to provide quality care. Please assist us by filling out this new patient record form. Your personal health information is kept private and secure as required by federal and state privacy.

PERSONAL DETAILS

Title: *

Given Name(s): *

Surname: *

Date of Birth: *

Birth Sex: *

MaleFemale

Gender Identification: *

Preferred Pronouns: *

Address: *

Street address *

Suburb *

State *

Postcode *

Mobile/ Phone Number *

Email Address *

Occupation:

HEALTH COVER

Medicare Number: *

Medicare Reference Number (number next to your name): *

Medicare Card Expiry Date: *

Concession Card CRN:

Consession Card Type

Expiry Date:

DVA Number:

DVA Card Type

DVA Conditions

Private Health Fund:

Private Health Number:

Were you referred to us? *

NoYes *Please fill in GP name and Practice details

If Yes, GP Name:

Practice Name:

Current GP Name/ Previous GP Name (if transferring care) *

Current Practice Name/ Previous Practice Name (if transferring care to our Practice) *

PARENTS (for children under the age of 16)

Full Name:

Date of Birth:

Address :

Street address

City

State

Postcode

Medicare Number :

Reference Number (number next to your name):

Expiry Date:

NEXT OF KIN

Full Name: *

Mobile Number: *

Relationship: *

EMERGENCY CONTACT

Emergency Contact Full Name: *

Emergency Contact Mobile Number: *

Emergency Contact Relationship: *

BACKGROUND

Knowing your cultural background helps us provide health care that meets your individual needs.

Do you identify as Aboriginal and/or Torres Strait Islander? *

If Yes, have you registered for closing the gap this year?

Yes No

Have you had a chronic illness for 6 months or longer? *

Details of Chronic illness:

You may be eligible for discounted or bulk billed health services. Ask your GP or reception about booking a Care Plan today.

CONSENT

Medusa Health Care collects information for the primary purpose of providing quality health care. *

I understand that it's not a bulk billing practice and I will need to pay a consult fee on the day (Medicare rebate available if eligible)I consent for my information to be collected and stored by Medusa Health CareI consent for correspondence being sent to third parties (GP, etc)I consent for correspondence being sent to My Health Record I consent to be contacted by SMS, email and phoneIf being seen by Bowel Diagnostics and Therpy, you consent to your initial consultation and investigations to be direct billed to Medicare

Date: *

Patients Full Name OR Parents name if the patient is under 16: *

Patients Signature OR Parents if the patient is under 16: *

Draw signature|Type signatureClear