NEAL STREET
MEDICAL CLINIC
Patient Information Form
We are committed to providing our patients with the best care. To do this it is essential that your health
record is kept up to date and accurate. Please complete the following.
Personal Information
Title
Surname
Given Names
Date of Birth
Home Address
Postal Address
Home Phone
Mobile Phone
Email
Occupation
Communication
My preferred method of contact is: Mail  Phone  Email  SMS
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Card Details
Medicare
No:
Health Care Card
No:
Expiry:
Pension Card
No:
Expiry:
DVA- Gold  White  No:
Expiry:
Private Health Insurance
Name:
Ref No:
Expiry:
No:
Next of Kin/Emergency Contact
Name
Phone Number
Relationship
Background
This section is optional and is used to tailor health initiatives for individual patients
1. Are you Aboriginal and/or Torres Strait Islander? Yes 
No 
2. Are you from a cultural or linguistic diverse background? Yes 
No 
3. If Yes, feel free to specify _______________________________
© Neal Street Medical Clinic 2014
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Medical History
Please list as much of your medical history as you can including operations and
conditions
Medications
Please list all medications you are taking at the moment.
Allergies
Do you have any general allergies, drug allergies or allergies to dressings?
☐ Yes
☐ No
Please explain __________________________________________________________
Family History
List any relevant family medical history
_______________________________________________________________________________
_______________________________________________________________________________
Social History
Are you a smoker? Yes  No  If yes, how long have you smoked? __________
How many do you smoke per day? __________
Do you drink alcohol? Yes  No  If yes, how many standard drinks per day ____
Do you use recreational drugs? Yes  No  ______________________________
Children’s Immunisations
If filling this form out for a child, are immunisations up to date? Yes 
No 
Females
Have you had a Pap Smear? Yes 
No 
If yes, date of last Pap Smear? ____________________
Billing
A copy of the Practice Fees will be available at reception. Alternatively it is also available on our website
www.nealstmc.com.au
I have read and understand the Billing policy of this practice. Yes  No 
© Neal Street Medical Clinic 2014
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Collection and Use of Your Information
We aim to protect the privacy and secure storage of your health information. You can
request a copy of our privacy policy, which includes information about the collection, use
and disclosure of your health information.
We require your consent to collect personal information about you and to use the
information you provide in the following ways. Please read this consent form carefully,
and sign where indicated below.
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To assess, diagnose, treat and be proactive in your health care needs.
Administrative purposes in running our medical practice.
Billing purposes, including compliance with Medicare and Health Insurance
Commission requirements.
Disclosure to others involved in your healthcare including treating doctors and
specialists outside this medical practice. This may occur though referral to other
doctors, or for medical tests and in the reports or results returned to us following
referrals.
Disclosure to other doctors in the practice, locums etc. attached to the practice for
the purpose of patient care and teaching.
For research and quality assurance activities to improve individual and community
health care and practice management. Usually information that does not identify
you is used but should information that will identify you be required you will be
informed and given the opportunity to “opt out” of any involvement.
To comply with any legislative or regulatory requirements e.g. notifiable diseases.
For reminder letters which may be sent to you regarding your health care and
management.
You can decline to have your health information used in all or some of the ways outlined
above but it may influence our ability to manage your health care to provide the best
outcome for you. You can discuss any concerns you have with our staff at anytime.
Signature: ________________________
Date: ______________________
If you have signed this form as a parent/guardian of a child
Print Name: ________________________
© Neal Street Medical Clinic 2014
Relationship: ____________________
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