Your Details

Title: Surname: Given Names:

Email: Date of Birth: Gender: Marital Status:

Medicare No: Ref No: Expiry Date: / Private Health Fund:

Pension, Health Care Card or Veterans Affairs Number (if applicable): Expiry Date: /

Occupation: Employer:

Home Address:

Postal Address (if different from Home Address):

Phone (Home): (Work): (Mobile):

Emergency Contact Details

Name: Relationship to you:

Phone (Home): (Work): (Mobile):

Australia is a genuinely multicultural society. To tailor appropriate care, encourage understanding and appreciation between people from different nationalities and backgrounds –Do you identify as someone from a culturally and/or linguistic diverse background?

Yes - Please indicate ethnicity:

To assist with health initiatives - are you Aboriginal or Torres Strait Islander?

List your allergies & intolerances to medications:

List your regular medications and doses & over the counter medications and doses:

Do you smoke?: If 'Yes' number per day: Year quit (if applicable):

Our practice undertakes research, professional development, and quality assurance/improvement activities to improve patient care. All people accessing personal health information for this purpose have signed a written confidentiality agreement.

I consent to my health record being reviewed as a part of the quality improvement activities in this practice:

Our practice uses a reminder system to improve the quality of your health care. The practice sends reminders by mail or telephone for procedures such as vaccinations, pap smears and other health reviews.

I consent to being contacted with reminders.

Please advise us if your contact information or Medicare details change.

You can also download the New Patient form to print and fill out. You can send it to us by:

Post: Shop 5-8/2 Como Crs Southport QLD 4215

Email: info@greenmed.com.au