PATIENT REGISTRATION FORM
	
We are committed to providing our patients with the best care.
To do this it is essential that your health record is up to date and accurate.

Could you please assist us by completing the following:	
Title		
First Name		
Surname		
Date of Birth		
			
Street Address		
Suburb and Post Code		
Postal Address (if different from above)		
Home Phone		
Work Phone		
Mobile Phone		
Email		
If we need to contact you, what is your preferred method of contact:	
□ Home Phone   □ Mobile   □ Work   □ Mail   □ Email	
			
Medicare Number:	Ref No: 	Expiry Date:	
□ DVA Card Number                   □ Gold   □ White	Expiry Date:	
□ Pension Card Number	Expiry Date:	
□ Health Care Card Number	Expiry Date:	
□ Private Health Cover 	Fund Name:	Expiry Date:	
Fund Number:                          □ Hospital Cover   □ Extras   □ Hospital cover and Extras	
		
Next of Kin
Name, Telephone Number and Relationship 		
Emergency Contact
Name, Telephone Number and Relationship		
			
Occupation:		
		
In What Country Were You Born? 	
		
To assist with health initiatives – are you Aboriginal or Torres Strait Islander?	
□ No     □ Aboriginal   □ Torres Strait Islander   □ Torres Strait Islander and Aboriginal
	
Do you have any allergies or are you sensitive to any drugs or dressings?	
□ No   □ Yes. 	Please elaborate	
Do you use any of the following: (list the amount where appropriate)	
Tobacco   	□ No	□ Yes	Average Per Day:	
Alcohol	□ No	□ Yes
	Average per Day:
Average Per Week:	
Other Drug Use	□ No	□ Yes
	Type:
Frequency:	
			
Patient History.  Have you ever had:	
□ Diabetes	□ Kidney Disease	□ Asthma	□ High Blood Pressure	
□ Heart Problems	□ Breast Cancer	□ Colon Cancer	□ Stroke	
□ Depression	□ Epilepsy	□ Other Cancer	
			
Previous Operations:
		
Previous Illnesses:
		
Current Medications:	

Family History.  Please tick any of the medical conditions	
□ Diabetes	□ Kidney Disease	□ Asthma	□ High Blood Pressure	
□ Heart Problems	□ Breast Cancer	□ Colon Cancer	□ Stroke	
□ Depression	□ Epilepsy	□ Other Cancer	
			
How Did You Hear About The Clinic?	
□ Newspaper	□ Word of Mouth	□ Pharmacy	□ Local Hospital	
□ Flyer	□ Internet	□ Walking By	Other:	
By becoming a patient at Morayfield Family Doctors and signing this new Patient form, I agree and consent to the following:
I consent to SMS appointment reminders for appointment reminders and recall appointments.
I consent to the use of my personal health information by Morayfield Family Doctors and other health care providers involved in my medical treatment and health care within this clinic.
I consent to the disclosure of my personal health information by the above named practice to other health care providers involved in my personal health care or medical treatment.
I consent to receive follow-up reminders and recalls to be sent to me, as part of the preventative health services offered by this practice, when follow-ups, recalls and routine investigations are due. 
By signing this form, you acknowledge to give a minimum of 3 hours’ notice to cancel doctors’ appointments and 24 hours’ notice to cancel chronic disease nurse & Allied Health appointments.  Failure to cancel or attend appointments may incur penalty fees.  
Signature: ________________________	 Date: ___ /___ /___	

Printed Name: ____________________