GP Registration Form

Thank you for completing this form.
Before you proceed, if you are concerned for your or someone else's safety, please contact 000 immediately.
All information is private and confidential, and is stored on a secure server.

Please ensure you read 'Your Rights and Responsibilities' document and the Privacy Statement before proceeding with this form.

What is your preferred centre? *

Personal Details

Given Name (first name): *

Surname (last name): *

Preferred Name:

Date of Birth: *

Title:

Gender: *

Pronouns:

Occupation: *

Contact Information

Mobile: *

Home Phone:

Email Address: *

Work Phone:

Can we leave a message? *

YesNo

Can we send you a SMS reminder? *

YesNo

Home Address: *

Suburb:

Postcode: *

Is your postal address different to your residential address? *

NoYes

Postal Address:

Suburb:

Postcode:

Are you or your immediate family homeless, or a risk of homelessness?

YesNo

Emergency Contact Details

Emergency Contact:

Emergency Contact's Number:

Emergency Contact Relationship:

Is your next of kin the same as your emergency contact?

YesNo

Next of Kin Contact:

Next of Kin Contact Number:

Next of Kin Relationship:

Do you have an advance care directive for end of life care? *

YesNo

(For more information talk to your GP)

Additional Information

Country of Birth: *

Cultural Background:

Preferred Language:

Do you need an interpreter? *

YesNo

If yes, which language? *

Do you have a carer? *

I have a carer who lives with meI have a carer who doesn't live with meI don't have a carer but I need one I do not need a carer

Carer's Contact Number:

Carer's Name:

Carer's Address:

Carer's Postcode:

Do you have any accessibility needs?

Do you have a Medicare card? *

YesNo

Medicare Card Number: *

Ref no: *

Medicare Card Expiry: *

Do you have a concession card?

NoHealth Care CardOther

Card Type:

Card Number:

Card Expiry Date:

Lifestyle

Smoking:

Non SmokerEx SmokerSmoker

How many times a day, week or month?

Current Alcohol:

Non DrinkerDrinker

How many standard drinks a day, week or month?

Medical History

Medications (including injections, vitamins and supplements):

Allergies and reactions:

Pre-existing medical conditions or surgeries:

I consent for my appointments to be bulk billed under Medicare *

I understand that my information may be shared with other staff at AccessHC or to other health professionals to allow quality medical care

I have received a copy of the brochure 'Rights and Responsibilities'

Signature *

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Date: *

Once you submit this form, you consent to headspace Hawthorn contacting you. The reception team will make every effort to contact you within 2 business days. Please call us on 9006-6500 if needed.

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