New Patient Registration Form – Highett Patient Registration Form - Highett Online Patient Registration Form for all new patients Patient Name* MrMrsMissMsDrProfRev Prefix First Last Gender* Male Female This field is hidden when viewing the formDate of Birth* DD slash MM slash YYYY Address* Street Address Suburb & Postcode Phone number*Mobile number*Work numberEmail* Medicare No.*Ref No.*Expiry*If patient is a minor Medicare No.Ref No.ExpiryPension / Health Care Card No.TypeCard TypePensioner Concession CardHealth Care CardCommonwealth Seniors Health CardExpiry DD slash MM slash YYYY DVA Card No.ColourCard ColourGoldWhiteOrangeExpiry DD slash MM slash YYYY Do you identify as someone from a culturally and/or linguistically diverse background? If yes, please elaborateAre you an Aboriginal or Torres Strait Islander?*Choose an ethnicityYes, - AboriginalYes - Torres Strait IslanderYes - both Aboriginal and Torres Strait IslanderNoDo you consent to receive SMS from our clinic to confirm appointments?* Yes No Our practice provides our patients with preventive care and early case detection reminders, e.g. immunisations, annual health checks, skin checks and cervical screening. Do you consent to participate?* Yes No Next Of KinEmergency Contact Person*Relationship to you?*Address* Street Address Suburb & Postcode Home phone numberMobile number*How did you hear about us?*Please select from the drop down menu optionsFriend or family memberGoogleWalked or driven bySocial mediaOtherPatient Consent - By completing and submitting this form I agree to the following privacy policy. We require your consent to enable us to handle personal information about you. We use a variety of reminder systems to maintain your health where reminders or recalls may be sent by post, email, telephone or SMS. This practice operates in accordance with the Privacy Act. Please read our privacy policy, and sign below. If you have any queries about this, feel free to ask us for further explanation. I have read the Privacy Policy of Atticus Health and I consent to the disclosure of my personal health information by Atticus Health to other health providers involved in my medical treatment and health care. As part of the preventative health and follow up service offered by Atticus Health, I consent to receive follow up reminders and recalls to be sent to the above address.Date* DD slash MM slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.
