COMING SOON Register as a patient now by completing the online patient registration form. Patient Registration Form Step 1 of 4 0% Patient DetailsTitle*Surname*Given Name/s*Date of Birth* Date Format: DD slash MM slash YYYY Gender*Please selectMaleFemaleOtherIf other, please specify*Marital Status*Please selectSingleMarriedDefactoSeparatedDivorcedWidowedMedicare No.*Ref No.Expiration DatePension, Health Care Card or DVA White/Gold Card Number:Expiration DateOccupationEmployerHome Address*Postcode*Postal Address*Postcode*Email* Phone (Home)Phone (Work)Phone (Mobile)* Next of KinName*Relationship to you*Phone (Mobile)*Phone (Home)Phone (Work)Emergency ContactName*Relationship to you*Phone (Mobile)*Phone (Home)Phone (Work)Do you identify as someone from a culturally and/or linguistic diverse background?*YesNoIf yes, Please indicate ethnicity*To assist with health initiatives - are you Aboriginal or Torres Strait Islander?*Yes - AboriginalYes - Torres Strait IslanderYes - Aboriginal & Torres Strait IslanderNo Health QuestionnaireAllergy to medication or food?*YesNoUnknownIf yes, Please specify*Smoker Status*Never SmokedEx-SmokerSmokerIf Ex-Smoker, Please specify year quitIf Smoker, Please specify no per dayAlcohol Intake*NilYesIf yes, please choose standard drinks/per*DayWeekMonthNo of drinks*Recreational Drugs*YesNoRegular Medications*NilYesIf yes, Please list below any medications and their doses if known – include over the counter medications and supplements* Current/Previous Medical Conditions*NilYesIf yes, please tick any that apply* Asthma Diabetes Type 1/Type 2 Heart Attack (MI) Stroke/CVA Pacemaker DVT Emphysema Depression and/or Anxiety Cancer HIV/AIDS Hepatitis A / B / C Epilepsy Other Please specify Cancer typeIf other, please specify*Family Medical History*NilYesIf yes, Please list below*Relation to you (e.g., mother, grandfather, sibling)Condition/s Our practice undertakes research, professional development, and quality assurance/improvement activities to improve patient care. All people accessing personal health information for this purpose have signed a written confidentiality agreement.I consent to my health record being reviewed and uploaded to My eHealth Record as a part of the quality improvement activities in this practice.*YesNoI give permission for my personal information to be collected, used and disclosed as described in this practice policy. I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.*YesNoOur practice uses a reminder system to improve the quality of your health care. The practice sends reminders by mail or telephone for procedures such as vaccinations, pap smears and other health reviews.*YesNoI consent to being contacted with reminders by sms/phone/email*YesNoCAPTCHA And follow us on Facebook for regular updates.