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New Patient Registration Form

Before your first visit, we ask that you provide the following information to assist Dr Melloy in providing you with the most suitable care. This information can also be provided via a written form on the day of your first visit.

Name

First Name

Last Name

Preferred Name

Date of birth

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Postal Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (Home)

(###)

###

####

Phone (Mobile)

(###)

###

####

Contact Person (Wife / husband / partner/ etc)

Name & Phone Number

Contact person phone number

Medicare Number

Medicare Expiry Date

Pension Card Number

DPT Vet Affairs Card Number

Work Cover (If Applicable)

Private Health Fund Name

Health Fund Member Number

Have you been with your health fund more than 12 months?

Yes

Do not have health insurance

Have you previously attended this practice?

Yes

Consent Message

This medical practice collects information from you for the primary purpose of providing quality health care. We ask you to provide us with your personal details and access to your medical history so that we may properly assess, diagnose and treat your health care needs. We will use the information you provide in the following ways. * Administration purposes in running our medical practice, including compliance with Medicare and Health Insurance requirements. This means we can obtain information regarding your Medicare number and your private health fund details from general practitioners, Medicare, health funds, hospitals and other health facilities. * For disclosure and to assist others involved in your health care, including treating doctors, specialists and hospitals outside this medical practice. * We also need your consent to collect information relevant to your health care from doctors, hospitals, pathology laboratories, x-ray facilities and other health facilities which may hold your medical records. * De-identified data of disease/treatment details may be used for quality assurance and audit activities.

Consent to Collect Information

We require your consent to collect personal details about you. Please read this consent message above carefully.

New Patient Registration Form

Before your first visit, we ask that you provide the following information to assist Dr Melloy in providing you with the most suitable care. This information can also be provided via a written form on the day of your first visit.

Dr Aemelia Melloy