NEW PATIENT
REGISTRATION FORM
We are committed to providing our patients with the best possible care.
To do this it is essential that your records are kept up to date. Please notify us of any changes ASAP.
We request that all clients contact us by phone for their pathology results unless advised otherwise.
Personal details
Title: Mr
Mrs
Miss
Other:
First name:
Surname:
Middle name:
Known as:
Date of Birth:
Sex:
Male / Female /
Email:
Street Address
Contact Numbers
Suburb
 Mobile:
State
P/code
 Work:
 Home:
Medicare details
Card number:
Ref no. on card:
Expiry Date:
List dependant family
(Name, Ref no. & DOB)
Private Hospital Insurance
Membership Number:
DVA Gold/White Card
Please circle
Number:
Ref:
Fund:
Expiry Date:
Condition/s (White Card only):
Pension/Health Care/
Comm. Seniors card
Please circle
Emergency Contact/
Next of Kin
Number:
Knowing your cultural
heritage can help us tailor
your healthcare.
Do you identify as:



Expiry Date:
Name:
Phone no:
Relationship:
Aboriginal
Torres Strait Islander?
Other (please specify)
 Yes  No
 Yes  No
…………………………………………………………..
Are you an interstate or overseas visitor to Alstonville?  Yes  No
Do you intend to have ongoing medical care provided by Alstonville Clinic?  Yes  No
If you answered yes to the above question, would you like us to request a copy of your medical records from your
previous surgery?  Yes  No
Our practice uses a reminder system to improve the quality of your health care. We send reminders by mail for
procedures such as pap tests and other health reviews. In future, we may elect to use email or SMS for reminders.
Please tick if you would like to have appointment reminders sent via email  Yes  No / SMS  Yes  No.
Signature: ………………………………………………………………………………….. Date: ……../……../…….