New Patient Form – Woodrising General Practice

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Patient information form

Enter ''NA/0'' If the required field is not applicable.

Title:

Surname:

Given Names:

Date of Birth:

Country of Birth:

Male Female

Address:

Phone (Home):

Work:

Mobile:

Email:

Medicare Number:

Ref No.(Line/Patient ID number):

Expiry Date:

DVA Number (Dept Veteran Affairs):

Expiry Date:

Health Care Card No:

Expiry Date:

Pension Card No:

Expiry Date:

Private Health Insurance:

Members No:

Do you identify as:

Australian Aboriginal Torres Strait Island

Other please Specify:

* Please specify “Next of Kin and emergency contacts" relationship to you.
Next of Kin:

Name:

Phone No:

Relationship:

Address:

Emergency Contact:

Name:

Phone No:

Relationship:

Address:

Health Information Collection Use Consent:
We require your consent to collect information about you and to use the information in the following ways:

Administrative Billing (Bulk billing) / Reminders/Recalls (Phone, SMS, email etc.) about your healthcare

Communication with other healthcare providers involved in your healthcare including treating allied health & Specialists.

Communication with other doctors within the surgery

To comply with any legislative or regulatory requirements e.g. Notifiable diseases

To provide de-indentified Patient data to third party which may be used for population health planning, advocacy initiative, Quality improvement activities, evaluation and research purpose

Date:

Enter ''NA/0'' If the required field is not applicable.

Patient Name:

Do you take recreational drugs?

Yes No

Do you Smoke?

Yes No

Number of Alcoholic Beverages per week

Do you have any allergies or sensitivities to medication or wound dressings

Yes No

If yes, please Specify:

Medications : Please list your current (Including over the counter) medication:

Marital Status:

Occupation:

Do you or have you ever suffered from any of the following - Please tick as required

Your past health History

Diabetes Hypertension Stroke Heart Disease Cancer Asthma COPD / Emphysema Osteoporosis Kidney Disease Depression / Mental Health

Family past health History (Mother and Father)

1.Diabetes
2.Hypertension
3.Stroke
4.Heart Disease
5.Cancer
6.Asthma
7.COPD / Emphysema
8.Osteoporosis
9.Kidney Disease
10.Depression / Mental Health

Mother Mother Mother Mother Mother Mother Mother Mother Mother Mother

Father Father Father Father Father Father Father Father Father Father

Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown Unknown

Any other:

Mother Father

Please list Recent and Past Operations

Operations:

Useful Links

After Hour Services
Medicare services – Department of Human Services
NSW Health – NSW Government
Centrelink – Department of Human Services
Australian Childhood Immunisation Register
Australian Govt Department of Health
Diabetes Australia
National Asthma Council

Opening Hours

Monday 9.00 am - 5:00 pm
Tuesday 9.00 am - 5:00 pm
Wednesday 9.00 am - 5:00pm
Thursday 9.00 am - 5:00pm
Friday 9.00 am - 5:00pm

GP After Hour Service

Call 13SICK (that’s 13 7425)

Online at 13SICK.COM.AU

2-4, 84 Hayden Brook Road Woodrising, 2284 NSW
Phone: 02 40672727 / Fax: 02 40672728

©2022 Woodrising General Practice. All Rights Reserved. Developed by Rex Technologies

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