NEW PATIENTS TO COMPLETE THIS FORM AND SUBMIT


ARE YOU OF TORRES STRAIT OR ABORIGINAL ORIGIN? *
ARE YOU OF TORRES STRAIT OR ABORIGINAL ORIGIN?
DO YOU CONSENT TO RECIEVE SMS REMINDERS ? *
DO YOU CONSENT TO RECIEVE SMS REMINDERS ?
PLEASE INDICATE GENDER *
GENDER?

Card Details:


MEDICARE CARD NO.
REF NO
3EXPIRY DATE
HEALTHCARE CARD / PENSION CARD / SENIORS CARD
4 DIGIT EXPIRY DATE
VETERANS AFFAIRS CARD
EXP DATE

Medical Information:


DO YOU HAVE DIABETES? *
DO YOU HAVE DIABETES?
DO YOU HAVE ANY CIRCULATION PROBLEMS? *
DO YOU HAVE ANY CIRCULATION PROBLEMS?
DO YOU TAKE ANY BLOOD THINNING MEDICATION? *
DO YOU TAKE ANY BLOOD THINNING MEDICATION?
DO YOU TAKE ANY OTHER MEDICATION? *
DO YOU TAKE ANY OTHER MEDICATION?
DO YOU HAVE ANY KNOWN ALLERGIES? *
DO YOU HAVE ANY KNOWN ALLERGIES?

Next of Kin Information:


FULL NAME
RELATIONSHIP
TEL HOME
TEL WORK
MOBILE NO.
HOW DID YOU HEAR ABOUT OUR CLINIC?
PARENT / GUARDIAN NAME AS SIGNATURE

Almeda Health Care Medical Clinic is committed to providing quality services to you and this policy outlines our ongoing obligations to you in respect of how we manage your personal information. We have adopted the National Privacy Principals ( NPPs) contained in the Privacy Policy Act 1988. The NPPs govern the way in-which we collect, use, disclose, share, secure and dispose of your Personal Information. A copy of the Australian Policy Principles may be obtained from the website of The Office of the Federal Commissioner at www.privacy.gov.au

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