New Patient Registration Form

Step 1:Your Name
Title *
First Name *
Surname *

Step 2:Your Contact Details
Telephone Number *
Email Address *
Address
Suburb
State
Postcode

Step 3:Your Identification
DOB
Age
Sex
Occupation

Step 4:Emergency Contact
Name *
Relationship *
Contact Number

Step 5:Referring Doctor
Full Name
Phone Number
Address

Step 6:Family Doctor
Full Name
Phone Number
Address

Step 7:Medical Information
Medicare Card Number
Ref No
Private Health Insurance Fund
Member No
Veterans Affairs No
Gold Card
Yes
No
Age or Disability Pension Card holder
Yes
No

Step 8:Health Conditions
Please select any conditions that you have been diagnosed with;
Health Conditions
Heart Attack
Heart Problems
Rhematic Fever
High Blood Pressure
Stroke
Diabetes
Asthma
Arthritis
Deep Vein Thrombosis
Pulmonary Embolus
Bleeding or bruising issues
HIV/AIDS
Hepatitis A. B or C
Ulcers (gastric. duodenal)
Anaemia
Cancer
Exmphysema
Epilepsy
Gout
Kidney Disease
Rheumatoid Arthritis
Sleep Apnoea
Are you currently taking any medication?
Yes
No
Please list any medication you
Do you smoke?
Yes
No
Do you suffer from allergies?
Yes
No
Please list any allergies

Step 9:Work Cover / TAC Claims
Is this a Work Cover or TAC claim?
Yes
No
Claim Number
Date of injury
Name of Insurance Company
Insurance Company Address
Case Managers Name Phone Number
Employers Name
Employers Phone Number
Employers Address

Patient Consent

To ensure quality care and practise we will collect personal information from you including but not limited to medicare details, health care provider and medical history. For billing and claiming purposes, we need to collect specific information to be provided to Medicare and Health Insurance Commissions. To ensure the best possible health care, we may also be required to share information you have provided with other health professionals and third parties (e.g., GP’s, Specialists, WorkSafe, TAC and/or Lawyers). By completing this form you give Matt Barnes permission to provide this information upon request, when a signed authority is provided to our rooms.

Alternatively, you can advise us of any information you wish to be kept private but understand this may affect your care. For further information on what data we collect and why, head to our Privacy Policy.