Erina Skin Cancer Clinic – Digital Patient Registration – Custom Forms

Step 1 of 6 - Patient Demographics

Patient Demographics
Title
First Name*
Surname*
Gender
Date of Birth*
DD slash MM slash YYYY
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
Were you born in Australia
Are you an Interstate or Overseas Visitor
Occupation
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
What drugs or dressings are you allergic or sensitive to
Do you take any Medications
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 Asthma
Do you have Diabetes
Do you have Hypertension (high blood pressure)
Do you have a chronic illness
Hidden
Enter extended medical information
Do you take recreational drugs
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

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

Privacy, Your Consent & Preventive Health (Recall & Reminder systems)
USE AND DISCLOSURE OF INFORMATION COLLECTED We will not disclose information about your individual visits to our website or any of the personal information that you provide such as your name, address, telephone number, e-mail address or credit/debit card details to any outside parties without your consent except when required by law to do so. We will only record your e-mail address if you send us a message. Your e-mail address will only be used or disclosed for the purpose for which you have provided it and it will not be added to a mailing list or for any other purpose without your consent unless you specifically request such action. Users are advised that there are inherent risks transmitting information across the internet.
Do you agree to receive SMS appointment reminders*
Do you agree to receive preventive care SMS*
Do you agree to receive quality assurance SMS*
Authority for a family member or Friend to collect patient information/scripts*
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