GPRC Patient Registration Form

The purpose of this respiratory clinic is to assess and treat people with mild to moderate respiratory conditions.

This clinic provides services to people with or without a Medicare card at no cost to the patient.

Personal Details

Surname (last name) *

First name *

Title *

Pronouns

Please provide pronoun details

Date of birth *

Sex at birth *

Work Information

Occupation

Home Address

Street number and name *

Suburb *

State *

Postcode *

Postal Address

Is your postal address the same as your home address? *

What is your postal address? *

Contact Details

Do you have a mobile telephone? *

What is your mobile number? *

Can we leave a message on your mobile? *

Can we send you an SMS reminder message? *

Do you have an email address? *

What is your email address? *

Can we email you? *

Do you have a home phone number? *

What is your home phone number? *

Can we leave a message on your home phone? *

Do you have a work phone number? *

What is your work phone number? *

Can we leave a message on your work phone? *

Emergency Contact Information

Emergency contact person's name *

Phone number for emergency contact *

Emergency contact’s relationship to you *

Is your Next of Kin contact the same as your Emergency Contact? *

Next of kin *

Next of kin's relationship to you *

Phone number for next of kin *

Cultural Background

What is your cultural background? *

Are you Aboriginal or Torres Strait Islander? *

YesNoPrefer not to say

Country of birth *

Preferred language *

Do you need an interpreter? *

If yes, which language?

Medicare Details

Do you have a current Medicare card? *

What is your Medicare card number? *

What is your reference number? *

Card expiry date *

Concession Card Details

Do you have a concession card? *

Which card do you have? *

Health Care CardPension Concession CardCommonwealth Seniors Health CardDVA

What is your card number? *

What is your card expiry date? *

Do you have a second concession card? *

Card type *

Health Care CardPension Concession CardCommonwealth Seniors Health CardDVA

What is the card number? *

What is your expiry date? *

Health Information

Do you have a regular GP? *

What is your regular doctor's name? *

What is the name of the medical practice where you see your doctor? *

What is the telephone number for your doctor? *

List any medications you are currently taking and the dose. Remember to include injections, vitamins and supplements. *

List any pre-existing medical conditions and previous surgeries *

Please tell us about any allergies or reactions you have had *

Lifestyle

Do you smoke? *

YesNoI used to smoke

How much do you smoke a day, week or month? *

How much did you smoke per day, week or month? *

Do you consume alcohol? *

YesNo

How many standard drinks do you have a week? *

Do you use any illicit drugs? *

NoI have previously usedI currently useI'd prefer not to say

Family History

If you selected 'other' please provide details *

Consent

I confirm that the above information I have provided is true, complete and accurate. *

I have read the AccessHC 'Rights and Responsibilities' and 'Privacy Statement' brochures. *

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

Signature *

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Today's date *