Name *

First Name

Last Name

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Mobile Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you of Aboriginal or Torres Strait Islander origin? *

Yes

No

If YES, do you consent to registering for Closing the Gap (CTG) with Medicare?

Yes

No

Patient Consent *

Our practice routinely uses text messages to send appointment reminders and recalls for any follow-up scheduled with your doctor. Please indicate if we can use your mobile number for these purposes:

Yes

No

Consent to use your health information *

National Prescribing Service (NPS) clinical audits, and various diseases registers to assist with preventative health management (e.g. cervical, breast and bowel screening), involve the doctor recording information on the treatment prescribed or recommended to patients with a particular illness. Please sign the Patient Consent Statement below if you agree to have your anonymous information used in such studies. Your medical care will not be affected in any way by your decision. If you would like further information about how your health information is used in these studies, please talk to your doctor.

I have read and understand the information above, and I agree to have my anonymous information included in the studies described.

Allergies *

Do you have allergies or are you sensitive to drugs/dressings

Yes (list below)

No

Parent / Guardian

If the patient is under 16 years of age

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

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