New Patient Information Forms

New Patient Information Forms

Welcome to Riverstone Family Medical Practice.  It will be helpful if we can obtain as much information as possible about you.  This information will be made available to the health practitioners in the Practice and relevant information may be shared with health professionals outside the Practice who have direct involvement in your medical care.  The information will not be given to anyone without your permission.

    New Patient Information Form - Adult

    First Name (required):
    Email (required):
    Street Number and Name:
    Phone No. (mobile if you have one) (required):









    If the practice needs to contact you and leave a message, we may use your:
        

    Next of Kin:

    Name (required):
    Relationship:






    Second Contact Person: (for emergencies)

    Name (required):
    Relationship:






    Ethnicity:

    What language(s) are spoken at home?




        

    Are you entitled to any of the following concessions?

    If you said yes to a Health Care Card please enter the Card Number, Expiry and Ref#?

    If you said yes to a Pension Card please enter the Card Number, Expiry and Ref#?

    If you said yes to a DVA Card please enter the Card Number, Expiry and Ref#?

    If you said yes to a Medicare Card please enter the Card Number, Expiry and Ref#?

    If you said yes to a Health Care Card please enter the Card Number, Expiry and Ref#?











    Please complete the following by selecting the correct answer.
    Have you suffered from ....

            


    Has anyone in your family (parents, brothers, sisters or children) suffered from any of the following illnesses?

            

    Thank you for your assistance.




    Privacy Act:   In line with the provisions of the Commonwealth Privacy Act (1988) and the National Privacy Principles, you are asked to give your consent to Riverstone Family Medical Practice for the collection and storage of your personal and health information. The information you provide will form part of your medical record and be stored in our computer system.

    It is necessary for us to collect personal information from our patients (and sometimes others associated with their health care) in order look after their health needs and for associated administrative purposes. No access to your health or other personal information, in any form, will be provided to any unauthorized person or to any person or organization outside of this practice without your permission.

    Cancellation Policy:   In consideration of our doctors and other patients, if you are unable to attend or need to change your appointment, please provide us with as much notice as possible so we can offer that appointment to those on the waiting list. Cancellation of consultations less than 2 hours prior or missed will incur a $30 fee which is not claimable from Medicare or Private Health Insurers.




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