Beach Road Surgery – Digital Patient Registration

Step 1 of 6 - Patient Demographics

Patient Demographics
Title
Given Names*
Preferred Name
Surname*
Date of Birth*
DD slash MM slash YYYY
Aboriginal or Torres Strait Islander
Sex
Gender Identity
Address
Street Address City ZIP / Postal Code
Mobile Phone*
Work Phone
Home Phone
Email*
Occupation
Are you
Number of Children
Please enter a number greater than or equal to 0.
I consent to being contacted with reminders by phone/sms/email to help me maintain my health*
Are you already registered for My Health Record*
Would you like us to register you for My Health Record*
Medicare Number
Medicare Reference
Medicare Expiry
Department of Veteran Affairs Card Type
DVA Number
Pension Card Type
Pension Number
Pension Expiry
DD slash MM slash YYYY

Next of Kin/Head of Family
Next of Kin First Name
Next of Kin Surname
Next of Kin Date of Birth
DD slash MM slash YYYY
Next of Kin Relationship to you
Next of Kin Phone

Emergency Contact
Emergency Contact First Name
Emergency Contact Surname
Emergency Contact Relationship to you
Emergency Contact Primary Phone
Emergency Contact Secondary Phone

Medical Details
Please detail any allergies you have
Please detail any medical problems you have
Please detail any medications you take
Do you smoke Cigarettes
Cigarettes per day
Ceased smoking date
DD slash MM slash YYYY
Do you drink alcohol
How many days a week do you drink alcohol
Please enter a number from 1 to 7.
Number of alcoholic drinks per session

Family History
Is your Mother still alive
Is your Father still alive
Has any member of your family been diagnosed with diabetes/ heart conditions/ breast cancer/ bowel cancer or any other form of cancer?*
Please provide illness and relationship to you*

CONSENT AND DECLARATION

I consent to Beach Road Surgery & Skin Clinic collecting, using, storing and disposing of my personal information and releasing relevant information to other Health Professionals to allow quality medical care. In the case of workers compensation claims or pre-employment medical related consultations I consent to the release of relevant personal information to my employer, their authorized representatives and their insurers.

I consent to the inclusion on the Beach Road Surgery & Skin Clinic recall reminder register.

I acknowledge I may receive correspondence by telephone, post, email or sms for follow up visits requested by the doctor, appointment reminders, medical updates and health information from Beach Road Surgery & Skin Clinic.

I understand that all accounts must be paid at the time of the consultation.
I am responsible for all accounts of any children under the age of 16 years who I am listed as next of kin.

I have read and understood the Beach Road Surgery & Skin Clinic Full Privacy Policy available on website or provided to me with this form. I acknowledge that Beach Road Surgery & Skin Clinic charges a fee for nonattendance and late cancellations of less than 24 hours notice. I acknowledge that Beach Road Surgery & Skin Clinic is a Private Billing Practice.
Patient or Parent/ Guardian Signature*
Date*
DD slash MM slash YYYY