MyClinic Bourke St Mall – Digital Patient Registration

Patient Demographics
Title
Pronoun
First Name*
Surname*
Preferred Name
Date of Birth*
DD slash MM slash YYYY
Address
Street Address City ZIP / Postal Code
Home Phone
Mobile Phone*
Email*
Medicare / DVA
Ref #
Expiry
Do you have a Healthcare/Pension card
Pension Card Type
Pension Number
Pension Expiry
DD slash MM slash YYYY
Are you an Overseas Visitor
Private Health Insurance
PHI Company
Policy #

Next of Kin
Next of Kin Name
Next of Kin Relationship to you
Next of Kin Phone

Emergency Contact
Emergency Contact First Name
Emergency Contact Surname
Emergency Contact Relationship to you
Emergency Contact Primary Phone

Cultural Details
Australia is generally a multicultural society. To tailor appropriate care, encourage understanding and appreciation between people from different nationalities and backgrounds. Do you identity as someone from a culturally and/or linguistic diverse background?
If yes, please elaborate i.e. country of birth
To assist with health initiatives are you:

Employment Details
Occupation
Do you have a current WorkCover claim?
IF YES, PLEASE SEE RECEPTION FOR FURTHER INSTRUCTIONS!

Medical Details
Do you have any allergies?
Please list your allergies
Do you take regular medications
Please list your regular medication
For Women Only - When did you have your last pap smear/cervical screening?
Was it normal?
Weight
Height

Social History
Do you currently smoke?
How many per day?
When did you stop smoking?
DD slash MM slash YYYY
Do you drink alcohol?
Days per week?
Please enter a number from 1 to 7.
Drinks per day?

Your Consents
HELP US MAKE OUR CLINIC A SAFE PLACE FOR EVERYONE. TREAT
EVERYONE WITH RESPECT.
Anyone who yells or otherwise threatens the safety of others will be asked to leave.
We require a minimum of 24 hours’ notice of cancellation of a scheduled appointment. Otherwise you will be charged a cancellation fee of $50. The cancellation fee is not Medicare rebate-able.

At MyClinic we provide an appointment reminder service which aims to decrease/prevent DNA’s (Did Not Attends). All patients who consent to SMS reminders are sent a reminder SMS for the appointment the day before.

Failure to attend without a minimum of 24 hours’ notice of cancellation will result in a $50 fee.
Privacy Policy & Patient Consent*
By signing below, you understand and agree to the following statements in relation to our use, collection, privacy and disclosure of your patient information. I have read the information above and understand the reasons why my information must be collected, and the purposes for which my information may be used or disclosed. I understand that if my information is to be used for any purpose other than that set out above, my further consent will be obtained. I give my permission for my personal information to be collected, used and disclosed as described above (including contact via SMS to my mobile phone number). I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.
Do you consent to being contacted via SMS for appointment reminders*
Do you consent to being contacted via SMS for clinical reminders (i.e careplan, vaccines, pap smears)*
Do you consent to being contacted via SMS for other medical services*
Patient Signature*
Date*
DD slash MM slash YYYY

Step 1 of 9 - Patient Demographics

Patient Demographics

Next of Kin

Emergency Contact

Cultural Details

Employment Details

Medical Details

Family History

Social History

Your Consents

HELP US MAKE OUR CLINIC A SAFE PLACE FOR EVERYONE. TREAT