PATIENT REGISTRATION FORM
Title: (Please indicate) Mr ⃝
Given Name:
Mrs ⃝
Ms ⃝
Miss ⃝ Dr ⃝
Surname:
Prof ⃝
Date of Birth:
Medicare Number: and Ref Number:
Country of Birth:
Expiry Date:
Pension Number: (if applicable)
Expiry Date:
Please present card to reception for verification
DVA Number: (if applicable)
Expiry Date:
Gold ⃝ White ⃝ Lilac ⃝ Orange ⃝
Address:
Phone: Home
Work
Email Address:
Next of Kin/In Case of Emergency:
Mobile
Name:
Address:
Relationship:
Phone Number:
Adding Other Family Members?
Name:
Date of Birth:
Name:
Date of Birth:
Name:
Date of Birth:
Do you identify as Aboriginal &/or Torres Strait Islander?
(Please indicate) YES ⃝
NO ⃝
Do not wish to say ⃝
Comments
Please read carefully before signing. Your signature will be taken as your agreement to what is set out below.
Name: ______________________________
Signature: _______________________________
Date ___ /___ /_____
I give my consent that information regarding my treatment be released to other specialist practitioners and or other Gladstone Street Medical Clinic
practitioners as necessary. Gladstone Street Medical Clinic acknowledges and respects the privacy of individuals. The personal information collected is
necessary for us to provide you with the best possible service. By completing this form, Gladstone Street Medical Clinic accepts that you, your
parents/guardians (if person is under 18 years of age) have consented for this information to be collected. The intended recipients of this information are
Gladstone Street Medical Clinic and its authorized staff. You have the right to access and alter personal information collected in accordance with the
Commonwealth Privacy Act (Amended 2001) and Gladstone Street Medical clinic Privacy Policy.
You may receive information from time to time regarding health issues and or recalls. This means we may also use the information you provide for:
- Administrative purpose in running the practice which may also include confirmation of your appointment via SMS texting or email
- Sending of your results of investigations to you via SMS or email.