{"id":1318,"date":"2022-01-11T03:26:05","date_gmt":"2022-01-11T03:26:05","guid":{"rendered":"https:\/\/www.healthsite.com.au\/customforms\/?page_id=1318"},"modified":"2022-01-11T03:26:47","modified_gmt":"2022-01-11T03:26:47","slug":"beach-road-surgery-digital-patient-registration","status":"publish","type":"page","link":"https:\/\/www.healthsite.com.au\/customforms\/beach-road-surgery-digital-patient-registration\/","title":{"rendered":"Beach Road Surgery &#8211; Digital Patient Registration"},"content":{"rendered":"<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper npr-form_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_7' style='display:none'><div id='gf_7' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_7' id='gform_7' class='npr-form gform_legacy_markup' action='\/customforms\/wp-json\/wp\/v2\/pages\/1318#gf_7' >\n        <div id='gf_progressbar_wrapper_7' class='gf_progressbar_wrapper'>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>6<\/span> - Patient Demographics\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_16' style='width:16%;'><span>16%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body gform-body'><div id='gform_page_7_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_7' class='gform_fields top_label form_sublabel_above description_above'><li id=\"field_7_69\"  class=\"gfield gsection section-heading field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_69\"><h2 class=\"gsection_title\">Patient Demographics<\/h2><\/li><li id=\"field_7_4\"  class=\"gfield gf_left_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_4\"><label class='gfield_label' for='input_7_4' >Title<\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_7_4' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Mr' >Mr<\/option><option value='Mrs' >Mrs<\/option><option value='Ms' >Ms<\/option><option value='Miss' >Miss<\/option><option value='Master' >Master<\/option><option value='Dr' >Dr<\/option><\/select><\/div><\/li><li id=\"field_7_39\"  class=\"gfield gf_middle_third gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_39\"><label class='gfield_label' for='input_7_39' >Given Names<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_7_39' type='text' value='' class='medium' maxlength='40'    aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_149\"  class=\"gfield gfield--width-full gf_right_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_149\"><label class='gfield_label' for='input_7_149' >Preferred Name<\/label><div class='ginput_container ginput_container_text'><input name='input_149' id='input_7_149' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_38\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_38\"><label class='gfield_label' for='input_7_38' >Surname<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_7_38' type='text' value='' class='medium' maxlength='30'    aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_9\"  class=\"gfield gfield--width-full gf_right_half gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_9\"><label class='gfield_label' for='input_7_9' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_9' id='input_7_9' type='text' value='' class='datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_7_9_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_7_9_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_9' class='gform_hidden' value='https:\/\/www.healthsite.com.au\/customforms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_13\"  class=\"gfield gfield--width-full field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_13\"><label class='gfield_label' for='input_7_13' >Aboriginal or Torres Strait Islander<\/label><div class='ginput_container ginput_container_select'><select name='input_13' id='input_7_13' class='large gfield_select'     aria-invalid=\"false\" ><option value='Neither Aboriginal or Torres Strait Islander' >Neither Aboriginal or Torres Strait Islander<\/option><option value='Aboriginal' >Aboriginal<\/option><option value='Torres Strait Islander' >Torres Strait Islander<\/option><option value='Both Aboriginal &amp; Torres Strait Islander' >Both Aboriginal &amp; Torres Strait Islander<\/option><\/select><\/div><\/li><li id=\"field_7_8\"  class=\"gfield gf_left_half field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_8\"><label class='gfield_label' for='input_7_8' >Sex<\/label><div class='ginput_container ginput_container_select'><select name='input_8' id='input_7_8' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' ><\/option><option value='Female' >Female<\/option><option value='Male' >Male<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_7_150\"  class=\"gfield gfield--width-full gf_right_half field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_150\"><label class='gfield_label' for='input_7_150' >Gender Identity<\/label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_7_150' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_144\"  class=\"gfield gfield--width-full field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_144\"><label class='gfield_label gfield_label_before_complex'  >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address' id='input_7_144' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1' id='input_7_144_1_container' >\n                                        <label for='input_7_144_1' id='input_7_144_1_label' >Street Address<\/label>\n                                        <input type='text' name='input_144.1' id='input_7_144_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city' id='input_7_144_3_container' >\n                                    <label for='input_7_144_3' id='input_7_144_3_label' >City<\/label>\n                                    <input type='text' name='input_144.3' id='input_7_144_3' value=''    aria-required='false'    \/>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_144.4' id='input_7_144_4' value=''\/><span class='ginput_right address_zip ginput_address_zip' id='input_7_144_5_container' >\n                                    <label for='input_7_144_5' id='input_7_144_5_label' >ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_144.5' id='input_7_144_5' value=''    aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_144.6' id='input_7_144_6' value='Australia' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_133\"  class=\"gfield gf_left_third gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_133\"><label class='gfield_label' for='input_7_133' >Mobile Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_7_133' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_137\"  class=\"gfield gf_middle_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_137\"><label class='gfield_label' for='input_7_137' >Work Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_137' id='input_7_137' type='text' value='' class='medium'    placeholder='Include area code e.g. 03XXXXXXXX'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_138\"  class=\"gfield gf_right_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_138\"><label class='gfield_label' for='input_7_138' >Home Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_7_138' type='text' value='' class='medium'    placeholder='Include area code e.g. 03XXXXXXXX'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_29\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_29\"><label class='gfield_label' for='input_7_29' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_29' id='input_7_29' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_7_11\"  class=\"gfield gfield--width-full gf_right_half field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_11\"><label class='gfield_label' for='input_7_11' >Occupation<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_7_11' type='text' value=' ' class='medium' maxlength='50'     aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_156\"  class=\"gfield gfield--width-full gf_left_half field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_156\"><label class='gfield_label' for='input_7_156' >Are you<\/label><div class='ginput_container ginput_container_select'><select name='input_156' id='input_7_156' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Child' >Child<\/option><option value='Married' >Married<\/option><option value='De facto' >De facto<\/option><option value='Single' >Single<\/option><option value='Widowed' >Widowed<\/option><option value='Divorced' >Divorced<\/option><\/select><\/div><\/li><li id=\"field_7_158\"  class=\"gfield gfield--width-full gf_right_half field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_158\"><label class='gfield_label' for='input_7_158' >Number of Children<\/label><div class='ginput_container ginput_container_number'><input name='input_158' id='input_7_158' type='text'    value='' class='medium'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_7_158\" \/><div class='instruction ' id='gfield_instruction_7_158'>Please enter a number greater than or equal to <strong>0<\/strong>.<\/div><\/div><\/li><li id=\"field_7_59\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_59\"><label class='gfield_label' for='input_7_59' >I consent to being contacted with reminders by phone\/sms\/email to help me maintain my health<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_59' id='input_7_59' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_7_151\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_151\"><label class='gfield_label' for='input_7_151' >Are you already registered for My Health Record<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_151' id='input_7_151' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_7_152\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_152\"><label class='gfield_label' for='input_7_152' >Would you like us to register you for My Health Record<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_152' id='input_7_152' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_7_17\"  class=\"gfield gf_left_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_17\"><label class='gfield_label' for='input_7_17' >Medicare Number<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_7_17' type='text' value='' class='medium'    placeholder='10 digits long'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_18\"  class=\"gfield gf_middle_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_18\"><label class='gfield_label' for='input_7_18' >Medicare Reference<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_7_18' type='text' value='' class='medium'    placeholder='Single number next to your name'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_166\"  class=\"gfield gfield--width-full gf_right_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_166\"><label class='gfield_label' for='input_7_166' >Medicare Expiry<\/label><div class='ginput_container ginput_container_text'><input name='input_166' id='input_7_166' type='text' value='' class='large'    placeholder='yyyy-mm'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_35\"  class=\"gfield gfield--width-full gf_left_half field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_35\"><label class='gfield_label' for='input_7_35' >Department of Veteran Affairs Card Type<\/label><div class='ginput_container ginput_container_select'><select name='input_35' id='input_7_35' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Gold' >Gold<\/option><option value='White' >White<\/option><\/select><\/div><\/li><li id=\"field_7_139\"  class=\"gfield gfield--width-full gf_right_half field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_139\"><label class='gfield_label' for='input_7_139' >DVA Number<\/label><div class='ginput_container ginput_container_number'><input name='input_139' id='input_7_139' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_7_34\"  class=\"gfield gfield--width-full gf_left_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_34\"><label class='gfield_label' for='input_7_34' >Pension Card Type<\/label><div class='ginput_container ginput_container_select'><select name='input_34' id='input_7_34' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Pensioner Concession Card' >Pensioner Concession Card<\/option><option value='Health Care Card' >Health Care Card<\/option><option value='Commonwealth Seniors Health Card' >Commonwealth Seniors Health Card<\/option><\/select><\/div><\/li><li id=\"field_7_140\"  class=\"gfield gf_middle_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_140\"><label class='gfield_label' for='input_7_140' >Pension Number<\/label><div class='ginput_container ginput_container_number'><input name='input_140' id='input_7_140' type='text'    value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_7_67\"  class=\"gfield gf_right_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_67\"><label class='gfield_label' for='input_7_67' >Pension Expiry<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_67' id='input_7_67' type='text' value='' class='datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_7_67_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_67_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_67' class='gform_hidden' value='https:\/\/www.healthsite.com.au\/customforms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_7_120' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_7\").val(\"2\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_7\").val(\"2\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_2' class='gform_fields top_label form_sublabel_above description_above'><li id=\"field_7_36\"  class=\"gfield gsection section-heading field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_36\"><h2 class=\"gsection_title\">Next of Kin\/Head of Family<\/h2><\/li><li id=\"field_7_40\"  class=\"gfield gf_left_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_40\"><label class='gfield_label' for='input_7_40' >Next of Kin First Name<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_7_40' type='text' value='' class='medium' maxlength='40'     aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_41\"  class=\"gfield gf_middle_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_41\"><label class='gfield_label' for='input_7_41' >Next of Kin Surname<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_7_41' type='text' value='' class='medium' maxlength='30'     aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_165\"  class=\"gfield gfield--width-full gf_right_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_165\"><label class='gfield_label' for='input_7_165' >Next of Kin Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_165' id='input_7_165' type='text' value='' class='datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_7_165_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_165_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_165' class='gform_hidden' value='https:\/\/www.healthsite.com.au\/customforms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_42\"  class=\"gfield gf_left_half field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_42\"><label class='gfield_label' for='input_7_42' >Next of Kin Relationship to you<\/label><div class='ginput_container ginput_container_text'><input name='input_42' id='input_7_42' type='text' value='' class='medium' maxlength='20'     aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_141\"  class=\"gfield gf_right_half field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_141\"><label class='gfield_label' for='input_7_141' >Next of Kin Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_7_141' type='text' value='' class='medium'    placeholder='Include area code if not mobile e.g. 03XXXXXXXX'  aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_121' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_7\").val(\"1\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_7\").val(\"1\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_7_121' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_7\").val(\"3\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_7\").val(\"3\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_3' class='gform_fields top_label form_sublabel_above description_above'><li id=\"field_7_44\"  class=\"gfield gsection section-heading field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_44\"><h2 class=\"gsection_title\">Emergency Contact<\/h2><\/li><li id=\"field_7_45\"  class=\"gfield gf_left_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_45\"><label class='gfield_label' for='input_7_45' >Emergency Contact First Name<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_7_45' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_108\"  class=\"gfield gf_middle_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_108\"><label class='gfield_label' for='input_7_108' >Emergency Contact Surname<\/label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_7_108' type='text' value='' class='medium'      aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_110\"  class=\"gfield gf_right_third field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_110\"><label class='gfield_label' for='input_7_110' >Emergency Contact Relationship to you<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_7_110' type='text' value='' class='medium' maxlength='20'     aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_142\"  class=\"gfield gf_left_half field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_142\"><label class='gfield_label' for='input_7_142' >Emergency Contact Primary Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_7_142' type='text' value='' class='medium'    placeholder='Include area code if not mobile e.g. 03XXXXXXXX'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_7_143\"  class=\"gfield gf_right_half field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_143\"><label class='gfield_label' for='input_7_143' >Emergency Contact Secondary Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_7_143' type='text' value='' class='medium'    placeholder='Include area code if not mobile e.g. 03XXXXXXXX'  aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_122' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_7\").val(\"2\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_7\").val(\"2\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_7_122' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_7\").val(\"4\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_7\").val(\"4\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_4' class='gform_fields top_label form_sublabel_above description_above'><li id=\"field_7_49\"  class=\"gfield gsection section-heading field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_49\"><h2 class=\"gsection_title\">Medical Details<\/h2><\/li><li id=\"field_7_153\"  class=\"gfield gfield--width-full field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_153\"><label class='gfield_label' for='input_7_153' >Please detail any allergies you have<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_153' id='input_7_153' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_154\"  class=\"gfield gfield--width-full field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_154\"><label class='gfield_label' for='input_7_154' >Please detail any medical problems you have<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_154' id='input_7_154' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_155\"  class=\"gfield gfield--width-full field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_155\"><label class='gfield_label' for='input_7_155' >Please detail any medications you take<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_155' id='input_7_155' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_52\"  class=\"gfield field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_52\"><label class='gfield_label' for='input_7_52' >Do you smoke Cigarettes<\/label><div class='ginput_container ginput_container_select'><select name='input_52' id='input_7_52' class='large gfield_select'     aria-invalid=\"false\" ><option value='Never smoked' >Never smoked<\/option><option value='Ceased smoking' >Ceased smoking<\/option><option value='Smoker' >Smoker<\/option><\/select><\/div><\/li><li id=\"field_7_72\"  class=\"gfield field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_72\"><label class='gfield_label' for='input_7_72' >Cigarettes per day<\/label><div class='ginput_container ginput_container_number'><input name='input_72' id='input_7_72' type='text'    value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_7_73\"  class=\"gfield field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_73\"><label class='gfield_label' for='input_7_73' >Ceased smoking date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_73' id='input_7_73' type='text' value='' class='datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_7_73_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_73_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_73' class='gform_hidden' value='https:\/\/www.healthsite.com.au\/customforms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_53\"  class=\"gfield field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_53\"><label class='gfield_label' for='input_7_53' >Do you drink alcohol<\/label><div class='ginput_container ginput_container_select'><select name='input_53' id='input_7_53' class='large gfield_select'     aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/li><li id=\"field_7_74\"  class=\"gfield field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_74\"><label class='gfield_label' for='input_7_74' >How many days a week do you drink alcohol<\/label><div class='ginput_container ginput_container_number'><input name='input_74' id='input_7_74' type='text'    value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_7_74\" \/><div class='instruction ' id='gfield_instruction_7_74'>Please enter a number from <strong>1<\/strong> to <strong>7<\/strong>.<\/div><\/div><\/li><li id=\"field_7_75\"  class=\"gfield field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_75\"><label class='gfield_label' for='input_7_75' >Number of alcoholic drinks per session<\/label><div class='ginput_container ginput_container_number'><input name='input_75' id='input_7_75' type='text'    value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_123' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_7\").val(\"3\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_7\").val(\"3\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_7_123' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_7\").val(\"5\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_7\").val(\"5\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_5' class='gform_fields top_label form_sublabel_above description_above'><li id=\"field_7_94\"  class=\"gfield gsection section-heading field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_94\"><h2 class=\"gsection_title\">Family History<\/h2><\/li><li id=\"field_7_159\"  class=\"gfield gfield--width-full gf_left_half field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_159\"><label class='gfield_label' for='input_7_159' >Is your Mother still alive<\/label><div class='ginput_container ginput_container_select'><select name='input_159' id='input_7_159' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_7_160\"  class=\"gfield gfield--width-full gf_right_half field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_160\"><label class='gfield_label' for='input_7_160' >Is your Father still alive<\/label><div class='ginput_container ginput_container_select'><select name='input_160' id='input_7_160' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_7_161\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_161\"><label class='gfield_label' for='input_7_161' >Has any member of your family been diagnosed with diabetes\/ heart conditions\/ breast cancer\/ bowel cancer or any other form of cancer?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_161' id='input_7_161' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/li><li id=\"field_7_162\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_162\"><label class='gfield_label' for='input_7_162' >Please provide illness and relationship to you<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_162' id='input_7_162' class='textarea medium'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_7_124' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_7\").val(\"4\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_7\").val(\"4\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_7_124' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_7\").val(\"6\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_7\").val(\"6\");  jQuery(\"#gform_7\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_6' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_6' class='gform_fields top_label form_sublabel_above description_above'><li id=\"field_7_163\"  class=\"gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_163\"><div>\n  <div style=\"font-weight: 600; text-align: center;\">CONSENT AND DECLARATION<\/div>\n  <div>I consent to Beach Road Surgery & Skin Clinic collecting, using, storing and disposing of my personal information and releasing relevant information to other Health Professionals to allow quality medical care. In the case of workers compensation claims or pre-employment medical related consultations I consent to the release of relevant personal information to my employer, their authorized representatives and their insurers.<\/div>\n  <br \/>\n  <div>I consent to the inclusion on the Beach Road Surgery & Skin Clinic recall reminder register.<\/div>\n  <br \/>\n  <div>I acknowledge I may receive correspondence by telephone, post, email or sms for follow up visits requested by the doctor, appointment reminders, medical updates and health information from Beach Road Surgery & Skin Clinic.<\/div>\n  <br \/>\n  <div>I understand that all accounts must be paid at the time of the consultation. <br \/> I am responsible for all accounts of any children under the age of 16 years who I am listed as next of kin. <\/div>\n  <br \/>\n  <div style=\"font-weight: 600;\">I have read and understood the Beach Road Surgery & Skin Clinic Full Privacy Policy available on website or provided to me with this form. I acknowledge that Beach Road Surgery & Skin Clinic charges a fee for nonattendance and late cancellations of less than 24 hours notice. I acknowledge that Beach Road Surgery & Skin Clinic is a Private Billing Practice.<\/div>\n<\/div><\/li><li id=\"field_7_129\"  class=\"gfield gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_129\"><label class='gfield_label' for='input_7_129' >Patient or Parent\/ Guardian Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_7_129_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_7_129_valid' id='input_7_129_valid' \/><canvas id='input_7_129' width='300' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_7_148\"  class=\"gfield gfield--width-full gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible\"  data-js-reload=\"field_7_148\"><label class='gfield_label' for='input_7_148' >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_148' id='input_7_148' type='text' value='14\/04\/2026' class='datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_7_148_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_7_148_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_148' class='gform_hidden' value='https:\/\/www.healthsite.com.au\/customforms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_7' class='gform_previous_button button' value='Previous'  onclick='if(window[\"gf_submitting_7\"]){return false;}  window[\"gf_submitting_7\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_7\"]){return false;} window[\"gf_submitting_7\"]=true;  jQuery(\"#gform_7\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_7' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_7\"]){return false;}  window[\"gf_submitting_7\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_7\"]){return false;} window[\"gf_submitting_7\"]=true;  jQuery(\"#gform_7\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=7&amp;title=&amp;description=&amp;tabindex=0' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_7' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='7' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_7' value='WyJbXSIsIjE3ZjVkNWY5NmNmZTAxYTdlMDBiNThkNjgzMmI5ODdjIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_7' id='gform_target_page_number_7' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_7' id='gform_source_page_number_7' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <\/div><\/div>\n                        <\/form>\n                        <\/div>\n                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_7' id='gform_ajax_frame_7' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 7, 'https:\/\/www.healthsite.com.au\/customforms\/wp-content\/plugins\/gravityforms\/images\/spinner.svg' );jQuery('#gform_ajax_frame_7').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_7');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_7').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! 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