New Patient Registration Form Please enable JavaScript in your browser to complete this form.Title *Dr.Mr.MrsMs.MissMasterName *FirstMiddleLastGender Identity *Select your GenderMaleFemaleNon-binaryGender DiverseTransgenderDifferent IdentityEmail address *Occupation *How did you hear about us? *Family-FriendWalk inChemistFacebookWeb SearchHealth EngineOtherAre you Aboriginal *Are you AboriginalYesNoAre you Torres Strait Islander *Torres Strait IslanderYesNoCountry of Birth *Language Spoken *Medicare No *Ref No *Exp Date *DVA NoColourExp DatePension/Health Card NoExp DateNext of Kin *Name *Emergency Contact *Emergency Contact Name *Do you have any Allergies* *Do you have any SymptomsHeightWeightWaist (cm) Pant/Skirt sizeDo you have history of any of the following *High blood pressureStrokeHeart diseaseDiabetesAsthmaChronic illnessCancerNoneOtherDo you take any medications *Surgical History: Please List *Immunisation: Please List *Last bowel cancer screening date *Female Patients onlyLast Breast Screen Do you have family history of any of the following? *High blood pressureStrokeHeart diseaseDiabetesAsthmaChronic illnessCancerOtherNonePlease mention ( if other)Smoking *NeverSmokerEx-SmokerAlcohol *NeverOccasionalRelationship statusDe-factorDivorcedEngagedMarriedNever marriedSeparatedWidowedPhysical activityInactiveModerate (e.g. Physical work)Active (e.g. Excercise program)Do you wish to have relevant health reminder sent to you *yesNoPatient Declaration *I agree, I provide consent for Austral Doctors Surgery and their affiliates to access and use my personal information so that they can provide me with the best possible healthcare. Only staff who need to see my personal information will have access to it.I provide consent for Austral Doctors Surgery to upload shared health summary online on My Health Records* *YesNoSubmit
