New patient registration form
Practice name
Section A: Personal details
Title Surname Given names
Date of birth (dd/mm/yy) Gender Marital status
/ /
Single Married Defacto Separated Divorced Widowed
Medicare card number Medicare reference number Medicare card expiry date
/ /
Pension, Health Care Card, or Veterans Affairs number (if applicable) Type of Veterans Affairs card Expiry date
/ /
Occupation
Home address Postcode
Postal address Postcode
Telephone number Work number Mobile number
Email
Who can we contact in an emergency?
Name Relationship to you
Telephone number Work number Mobile number
Do you have an advance health directive for end of life care?
Yes
No
For more information talk to your GP.
Please print letters
Use black or blue pen
Place
in all applicable boxes
RACGP Standards for general practices. This means your personal health information
is kept private and secure, as required by federal and state privacy laws. If you have
concerns, please leave blank and discuss with your GP.
Please notify us promptly of any changes in your contact details. Accurate contact
details help us identify you and your medical records, and allow us to contact you
promptly about tests and results.
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The Royal Australian College of General Practitioners New patient registration form
Section B: Cultural background
Knowing your cultural background can help us provide healthcare that meets your individual needs.
Are you of Aboriginal or Torres Strait Islander origin?
No
Yes, Aboriginal Yes, Torres Strait Islander Yes, both Aboriginal and Torres Strait Islander
Other cultural background (eg Mediterranean, Asian, African) Country of birth
If not, do you require an interpreter? Please specify language
Yes
No Yes No
Section C: Allergies and medicines
List allergies and intolerances to medications Describe your reaction
List regular medications and doses, and complementary medicines and doses
Section D: Consent
I consent to being contacted with reminders to help me maintain my health
Yes
No
Our practice also sends information to the Australian Childhood Immunisation Register and Pap Smear Register. These registers also
send reminders, which can be helpful if you move.
I consent to being contacted with reminders to help me maintain my health
Yes
No
Signature of patient or guardian Date
/ /
Section E: Transfer of health information
You may have consistently consulted with a GP at another practice. The health information held by that GP may assist us with your
future healthcare needs. You may wish to have a copy or a summary of your health records transferred to this practice. Please ask
the receptionist for information about how this can take place.
Please advise us if your contact information or Medicare details change.
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