Skip to content

"*" indicates required fields

Step 1 of 9 - Patient Demographics

11%

Patient Demographics

DD slash MM slash YYYY
Address

Next of Kin

Name

Emergency Contact

Name

Cultural Details

Employment Details

IF YES, PLEASE SEE RECEPTION FOR FURTHER INSTRUCTIONS!

Medical Details

Family History

Do you or members of your family have or have had Asthma?
Do you or members of your family have or have had Diabetes?
Do you or members of your family have or have had Hypertension?
Do you or members of your family have or have had Colon Cancer?
Do you or members of your family have or have had Heart Disease?
Do you or members of your family have or have had Depression?
Do you or members of your family have or have had a Stroke?
Do you or members of your family have or have had Breast Cancer?

Social History

Your Consents

HELP US MAKE OUR CLINIC A SAFE PLACE FOR EVERYONE. TREAT

EVERYONE WITH RESPECT.
Anyone who yells or otherwise threatens the safety of others will be asked to leave.

We require a minimum of 24 hours’ notice of cancellation of a scheduled appointment. Otherwise you will be charged a cancellation fee of $50. The cancellation fee is not Medicare rebate-able.

At MyClinic we provide an appointment reminder service which aims to decrease/prevent DNA’s (Did Not Attends). All patients who consent to SMS reminders are sent a reminder SMS for the appointment the day before.

Failure to attend without a minimum of 24 hours’ notice of cancellation will result in a $50 fee.

By signing below, you understand and agree to the following statements in relation to our use, collection, privacy and disclosure of your patient information. I have read the information above and understand the reasons why my information must be collected, and the purposes for which my information may be used or disclosed. I understand that if my information is to be used for any purpose other than that set out above, my further consent will be obtained. I give my permission for my personal information to be collected, used and disclosed as described above (including contact via SMS to my mobile phone number). I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.
DD slash MM slash YYYY