NEW PATIENT FORM Patient Title Select Dr Mr Mrs Ms Miss Mstr Mx Other Patient Name * First Name Last Name Patient Address Patient Date of Birth (dd/mm/yyyy) Patient Phone Number * Patient Mobile Number Patient Email * Patient Occupation Regular Doctor / Suburb Regular Dentist / Suburb Patient Medicare Number Patient Medicare Reference Number Medicare Expiry Do you have private health insurance? Select Yes No If you have private health insurance, please provide the following information: Name of Fund Membership Number Does patient have Private Hospital Cover? Select Yes No Does patient have Private Dental Cover? Select Yes No VET Affairs (if applicable) VET Affairs Number Vet Affairs Status For Medicare purposes, if a parent is responsible for the account, please provide the following information: Full Name of Parent/Yourself Parent Date of Birth (dd/mm/yyyy) Parent Medicare Number Parent Medicare Reference Number Medicare Expiry In Case of Emergency Name of Contact Relation Phone Patient Medical History Please check the box of any condition/status you have from the following list: Asthma Blood Pressure (High / Low) Diabetes Epilepsy Excessive Bleeding Heart Conditions Hepatitis Kidney Problems Osteoporosis Pregnant Rheumatic Fever Smoker Other Have you had any operations? Select Yes No If yes, please list operations: Do you have any allergies? Select Yes No If yes, please list allergies: Hepatitis and other viruses are of increasing concern in health care. Could you be in the high risk category of viral infection? Select Yes No Are you taking any medications? This includes oral contraceptive pill, asthma preparations, blood thinners, drugs for pain, arthritis, osteoporosis, anti-depressants, vitamins, herbal and Chinese supplements. Select Yes No If yes, please list medications: Do you give permission to be contacted by email, phone or text using the details provided in this form? Select Yes No Consent to Collect Patient Information - please read and consent below OMF Clinic collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history for optimum assessment, diagnosis, treatment and to be proactive in your health care needs. We will use the information you provide for administrative purposes in running our medical practice and billing purposes (including Medicare and health insurance commission requirements). Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice will be as advised by you. *I understand that I am not obligated to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me. *I am aware of my right to access the information collected about me, except in some circumstances where access may legitimately be withheld. *I understand that if my information is to be used for any purpose other than the above, my consent will be sought. *I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify. Consent: Date of consent (today's date): MM DD YYYY Your details have been successfully submitted. We will contact you shortly. If you have any enquiries in the meantime, please contact us by phone.
