Box Hill Superclinic – Digital Patient Registration

Step 1 of 6 - Patient Demographics

Patient Demographics
Title
First Name*
Surname*
Gender
Date of Birth*
DD slash MM slash YYYY
Marital Status
Mobile Phone*
Work Phone
Home Phone
Email*
Address
Street Address City ZIP / Postal Code
Medicare Number
Medicare Reference
Medicare Expiry
Aboriginal or Torres Strait Islander
Ethnicity
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Occupation
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Employer Name (Company Name)
Hidden
Occupation Year Started
Hidden
Occupation Year Ended
Hidden
Insurance Fund Name
Hidden
Insurance Fund Number
Hidden
Insurance Fund Expiry
DD slash MM slash YYYY
Pension Card Type
Pension Number
Pension Expiry
DD slash MM slash YYYY
Department of Veteran Affairs Card Type
DVA Number

Next of Kin
Next of Kin First Name
Next of Kin Surname
Next of Kin Relationship to you
Next of Kin Phone
Hidden
Next of Kin Secondary Phone

Emergency Contact
Emergency Contact First Name
Emergency Contact Surname
Emergency Contact Relationship to you
Emergency Contact Primary Phone
Emergency Contact Secondary Phone
Hidden
Emergency Contact Address
Hidden
Emergency Contact City
Hidden
Emergency Contact Postcode

Medical Details
Do you have any allergies or sensitivity to any drugs or dressings
Please list the drug or dressing you're allergic to and the reaction*
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What drugs or dressings are you allergic or sensitive to
Do you take any Medications
Please list each Medication and the dosage*
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What Medications do you currently take
Do you smoke Cigarettes
Cigarettes per day
Ceased smoking date
DD slash MM slash YYYY
Do you drink alcohol
How many days a week do you drink alcohol
Please enter a number from 1 to 7.
Number of alcoholic drinks per session
Do you have any past Medical conditions
Please list each condition and the year of diagnosis*
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Enter extended medical information
Height
Weight
Waist
Do you take recreational drugs
Are you part of the National Bowel Cancer Screening program
If registering a child, are their Immunisations up to date
When was your last Mammogram
DD slash MM slash YYYY
When was your last Pap Smear
DD slash MM slash YYYY
Do you have any other relevant conditions
What other relevant conditions do you have
Have you ever had an Operation
What Operation did you have
Date of your Operation
DD slash MM slash YYYY
How frequently do you exercise
How many days a week do you exercise
How long do you exercise per session

Family History
Diabetes
Asthma
Heart disease
Cancer
Other illnesses
What other illnesses are in your family history*
Depression
High cholesterol
Kidney disease
Respiratory problems

Privacy and Consent
Would you like to book for a Full Body Skin Cancer Check?*
(Out of pocket fees applies) visit www.sunskinclinic.com for more information
Are you due for a Pap smear?*
When was your last Pap smear?*
DD slash MM slash YYYY
How did you hear about us
Other method how you heard about us*
Workcover account terms: Please note that all Workcover-related consultations are privately billed at this clinic. It is the responsibility of the patient to cover these charges and make payment to the clinic during the time of the consultation and if applicable, to claim reimbursement directly with Workcover. To learn more about the Workcover-related consultation charges, please speak to one of our friendly receptionists before making an appointment.

Failure to attend policy: Please note that this clinic has a strict failure to attend policy whereby any non-attendances or late cancellations (less than 2 hours notice) will incur a $40 fee. You will need to make this payment before the clinic will accept any further appointments from you. For children and adults under care, the Next of Kin will be responsible for the payment.

All payments are due immediately. Any delay in payment will incur additional debt collection fees.

By signing below, I acknowledge that I have understood the above and will comply accordingly.

PRIVACY STATEMENT
Box Hill Superclinic (BHSC) respects your right to privacy and for the purposes of the Privacy Act 1988, considers all information you have provided in this form to be personal information. BHSC will treat this form as a confidential document.
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Terms and Conditions*
By checking this you are stating that you have answered all of the questions truthfully to the best of your knowledge. You are also agreeing to our terms and conditions, as well as our privacy policy
Signature*
Date*
DD slash MM slash YYYY
Open 7 days a week including all Public Holidays
Monday to Saturday 8AM - 10PM & Sunday 8AM - 7PM

No Appointments needed for URGENT CARE. WALK IN Accepted

On Site Pharmacy, Open 7 days

Physiotherapist | Cardiologist | Psychologist | Dietician | Gastroenterologist | Audiologist

BOX HILL SUPERCLINIC

810 Whitehorse Road (Free Patient Parking Via Prospect St)
Box Hill, VIC 3128

Online bookings available at www.boxhillsuperclinic.com.au & Box Hill Superclinic APP

Step 1 of 6 - Patient Demographics

Patient Demographics

Next of Kin

Emergency Contact

Medical Details

Family History

Privacy and Consent