New Patient Form

Are you completing this form on behalf of a child under the age of 17?

Yes

No

Is there a court order in place regarding custodial rights of the child?

Yes

No

Please note (if applicable) - Parents/Caregivers, if there is a Court Order in place for children from birth to 16 years regarding custodial rights of the child, then a copy of this Order is required for scanning into the child's medical chart.

Patient Details

Title

Please Specify

Gender

Please specify

First Name

Known as

Last Name

Date of Birth

Do you identify as:

Aboriginal

Torres Strait Islander

Address Details

Address Line 1

Address Line 2

Suburb

State

Post Code

Country

Do you have a different postal address?

Please check this box if your postal address is different to your home address.

Postal Address

Address Line 1

Address Line 2

Suburb

State

Post Code

Country

Contact Details

* Phone Numbers (please enter at least one)

Home

Work

Mobile

Email

Do you consent to receiving Emails?

Yes

No

Do you consent to receive SMS appointment reminders?

Yes

No

Next of Kin Details

Next to Kin (NOK)

Relationship to Patient

* Phone Numbers (please enter at least one)

Home

Work

Mobile

Emergency Contact is the same as Next of Kin

Emergency Contact Details

Emergency Contact Name

Relationship to Patient

* Phone Numbers (please enter at least one)

Home

Work

Mobile

MEDICARE & CONCESSION CARD INFORMATION

Do you have a Medicare card?

Yes

No

Medicare Card No

Reference Number (next to name)

Expiry Date (select any day of the month)

Payer's Medicare details

As the patient is under 17 years of age, please provide the payer's Medicare details:

Name

Reference No (next to name)

Date of Birth:

Concession Card No:

Concession Card Expiry Date:

By becoming a patient of Radius Medical Centre and signing this new patient form, I agree and consent to the following:

Consent1

I consent to the use of my personal health information by the Radius Medical Centre and other health care providers involved in my medical treatment and health care with this Centre.

Consent2

I consent to the disclosure of my personal health information by the above-named practice to other health care providers involved directly or indirectly in my personal health care or medical treatment.

Consent3

I consent to receive follow up reminders and recalls sent via SMS or mail to my contact details as part of preventative health services offered by this practice when routine investigations are due.

Consent4

I understand that a minimum of 2 hours’ notice to cancel or reschedule an appointment is required to avoid a fee.

Consent5

I understand that Schedule 8 scripts will not be prescribed at my initial appointment.

Patient/Guardian's Signature:

Sign Here

Date / Time

This information is private and confidential and is for use in your clinical file only.

Use of the personal information is limited to the bounds of our Privacy Policy

Patient Details

Address Details

Postal Address

Contact Details

Next of Kin Details

Emergency Contact Details

MEDICARE & CONCESSION CARD INFORMATION

Payer's Medicare details