New Patient Registration Form

Title:	Family Name:	First Names:
Date of Birth	__/__/____	Telephone	Mobile	Work
Address1:
Address2:
City/Suburb	State	Post Code
Email:	Occupation:
Medicare/DVA Card No:	Ref:	Pension Card No:
Private Health Insurance	Number:	Hospital/Extras/Both

Do you identify as: Aboriginal Torres Strait Islander Both

Are you registered for Closing the Gap Program? Yes/No If unsure please speak with Doctor of receptionist. Are you aware you are entitled to a health check? YES/NO

Have you served in the Australian Defence Forces? YES/NO

Country of Birth:	Cultural Background:
Next of Kin:	Relationship:	Phone:
Emergency Contact	Relationship:	Phone:
How did you hear about this surgery?

Tick this box if you authorise another person to contact the surgery on your behalf.

Nominated Person:

Tick this box if you would like SMS appointment confirmations and reminders. Please ensure a mobile number is listed above.

MEDICAL/SURGERY HISTORY (please tick appropriate box)

Condition	Family	Self	Medications*	Dosage*
Diabetes
High Blood Pressure
Heart Disease
Stroke
Bowel Cancer
Breast Cancer
Depression
Respiratory Illness (asthma emphysema)
Other:

*Your medications only. Click on return to insert extra lines.

Alcohol

How many standard Drinkers per day?	How many days per week?

Smoking History: Never Smoked: Ex Smoker: Current Smoker: (how many per day)______

What goals do you have for your health?

I_______________________ consent to North Lakes Doctors providing information to other health providers for the purpose of my ongoing health care, and to be part of National /State/Territory Reminders Systems/Registers or for use of Practice Enhancement Activities. (Personal information for Enhancement Activities is de-identified).

Signature:	Date:

Please print and bring this completed form with you to the appointment.