Register form | My Site

Registration form

Online Registration form

Personal Details

First Name

Last Name

Date of Birth

Country of birth

Ethnicity/Background

Are you an Aboriginal or Torres Trait Islander?

Street Address

Suburb

Post code

Phone

Occupation

Marital status

Medicare/Health insurance Details

Do you have Medicare card?

Yes

Medicare Number

Reference Number (in front of name)

Expirey date

Pension/Centrelink/Senior Card Number

Expiry date

If DVA

OSHC/Private health insurance company

Membership number

Expirey date

Family History

Has any member of your family been diagnosed with diabetes, a heart condition or any form of cancer?

Past Medical History

Have you been a patient in a hospital, if so for what reason and whitch year?

Are you diabetic?

Do you suffer from high blod pressure?

Yes

which type?

Have you ever suffered from chest pain or shortness of breath?

Yes

Are you allergic to any Medication?

When was your last pap smear? (Women only)

Social History

Do you smoke?

Have you previously smoked

Do you drink alchohol?

How many per day?

When did you give up smoking?

How many days per week?

SMS Booking Reminder

Yes

I understand that this practice complies with the Privacy Act (1998) and as part of their privacy of individuals and their personal information. My signature below indicates that I have read the above and consent to Dr Maclay General Practice collecting, using, storing, and disposing of my personal information. The release of relevant personal information to other health professionals to allow quality medical care

Your Signature

Thanks for registering.