New Patient Registration Title*MrMsMrsDoctorProfessorOtherFirst Name* Last Name* Date of birth* MM slash DD slash YYYY Home Phone*Mobile Phone*Address* Address Line 1 Address Line 2 Suburb Post Code Email* Private Email Consent* Yes No Please confirm the practice can use this private email address for administrative purposes e.g. confirming appointments, financial consent and on occasion, sending confidential information to you, to facilitate your care.Referring Doctor* Usual Doctor Other Doctor Medicare No.* Medicare No. next to name*Private Health Fund Private Health Fund No. Health Care Card/Pensioner Concession Card NoHCC/PCC Expiry Date MM slash DD slash YYYY Department of Veterans Affairs Card No.Department of Veterans Affairs Expiry Date MM slash DD slash YYYY Next of Kin Name Relationship Are you a Diabetic?* Yes No Diabetes Medication* Diet controlled Tablets Insulin Other Not applicable Do you take Anticoagulant medication or "blood thinners"?* Yes No Anticoagulant Medication* warfarin (Coumadin) clopidogrel (Iscover, Plavix, CoPlavix) rivaroxaban (Xarelto) dabigatran (Pradaxa) aspirin (Cartia) enoxaparin (Clexane) heparin apixaban (Eliquis) other Not Applicable Regular Medications Arrangement of Fees Payment is expected on the day of consultation. Pensioner Concession Card (PCC) and Health Care Card (HCC) holders will be charged a reduced fee (in excess of Medicare Benefit Schedule (MBS) fee). Patients covered by Veteran's Affairs and Workcover will not incur any fees, but any costs generated as a result of collecting fees will be passed onto the patient. Patients without these concessions will be charged standard fees. Patients who require hospital procedures will be provided with informed financial consent. You will be charged the consulting fee if you cancel an appointment within 24 hours of scheduled time. PrivacyThe information given is correct to my knowledge and I have read and understand the above 'Arrangement of Fees'.* Agree I understand the types of personal information collected by the Practice, the reasons why it is necessary to collect it and the circumstances in which my personal information may be used or disclosed.* Agree I understand that I may request access to my personal information, which may be granted in accordance with the practice's Access to Personal Information Policy. I will be provided with a written reason if access is denied.* Agree I understand that I may request an amendment to may personal information if it is incorrect. I will be provided with a written reason if a request for amendment is denied.* Agree I understand that my personal information will not be used for direct marketing or disclosed to overseas recipients.* Agree I understand that I am not obliged to provide the Practice with my personal information, but withholding information may limit the Practice's ability to provide me with full service.* Agree I understand that I have the right to lodge a complaint about the handling of my personal information if I am dissatisfied, which will be dealt with in accordance with the Practice's complaint handling procedure.* Agree I give permission for my information to assist with training and education of other health care professionals.* Agree Disagree