PATIENT REGISTRATION

Patient Registration Form

Title

DOB

First Name

Surname

Address

Suburb

Post code

State

Phone Number

Email

Occupation

Allergies

Current Medications Taken

Do you have any symptoms or specific concerns regarding your health?

Name of General Practitioner

Medicare Number

Ref Number

Expiry

DVA (if applicable)

Title

Health Care / Pension Card (if applicable):

Expiry

Private Health (if applicable)

Private Health

Next of Kin / Emergency Contact Name

Relationship to you

Contact No

1:- I consent to the secure handling of my information by East Coast Cardiology, in accordance with The Privacy Act of 1988, subject to any limitations on access or disclosure that I notify the practice of.


2:- I give permission for East Coast Cardiology to contact my nominated next of Kin/emergency Contact for Appointments/reminders/ follow up if I’m not contactable.


3:- I give East Coast Cardiology the permission to release/disclose my personal and medical information to any requesting professional (including but not limited to Specialists/General Practitioners/Hospitals/ Allied health/Insurance company/Medicare).


4:- I give East Coast Cardiology the permission to contact other Medical and non-medical professionals (including but not limited to Specialist / General Practitioner / Hospital / Allied Health/ Medicare Australia / PRODA) to obtain any information regarding myself, my previous/future consultations, tests and hospitalisations.


5:- I confirm that the above information is true, complete and accurate.

Signature (Print Name)

Date