Patient Registration Form

1. PATIENT DETAILS

First Name

Last Name

Preferred Name

Date of Birth

Sex at birth

MaleFemale

Height (cm)

Weight (kg)

BMI

English is a second language

YesNo

Is an interpreter required?

YesNo

Language

ATSI

AboriginalTorres Strait IslanderNone of the Above

If an interpreter is required, this must be arranged by the patient.

Visit https://www.service.nsw.gov.au/transaction/book-interpreter for more information.

2. PATIENT CONTACT DETAILS

Home Phone

Mobile Phone

Work Phone

Email

Address

City / Suburb

State

Postcode

3. NEXT OF KIN / EMERGENCY CONTACT DETAILS

Next of kin - Name

Next of kin - Email

Next of kin - Home Phone

Next of kin - Mobile Phone

Best way to contact your next of kin

Home PhMobile PhWork Ph

4. GENERAL PRACTITIONER

Family Doctor/ Regular General Practitioner name

Practice Name

Practice Number

Practice Fax

Practice Email

Address

5. REFERRING DOCTOR TO US (if different to GP)

If you were referred to Dr Brown as an inpatient at Royal North Shore Hospital or North Shore Private Hospital, check this box and skip to the next section.

Referring doctor’s name (if different to GP)

Contact Number

Referrer Fax

Referrer Email

Address

6. REFERRAL

Other reason:

Please attach referral if available

Browse

A scanned copy or photograph are acceptable. If using your smartphone or tablet to complete this form, you can upload a photo directly after clicking, 'Browse".

7. SCANS AND BLOOD TESTS

Have you had recent blood tests?

YesNo

If so, what was the approximate date?

Please list the pathology provider where you had your blood taken

Have you previously had any scans?

YesNo

These may include ultrasound, CT or MRI scans

Please list the type of scan, which radiology provider performed your scan, and the approximate date of the scan

8. MEDICARE

Do you use a different name on your Medicare card?

YesNo

If you use Alias please write the Alias name & surname

Medicare First Name

Medicare Surname

Medicare Card Number

Medicare Reference Number

Expiry

9. PRIVATE HEALTH INSURANCE

Do you have private medical insurance?

YesNo

Admitted as private patient?

YesNo

Provider

Membership No.

Expiry

10. PENSION / HCC / DVA CARD

Do you have an aged pension card, healthcare card or a DVA card? (not including a Seniors Card)

YesNo

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

DVA No.

11. PRE-EXISTING MEDICAL CONDITIONS

Do you have any of the following conditions?

DiabetesHeart DiseaseHigh Blood PressureHigh Cholesterol

Please list any other medical conditions and specialists involved

Please list any previous surgeries, including dates and surgeon name

Do you smoke?

YesNoEx-smoker

If yes, how many per week?

Do you drink alcohol?

YesNo

If yes, how many standard drinks per week?

12. MEDICATIONS / ALLERGIES

Do you take any blood thinners?

YesNo

Including any of the following: Aspirin / Plavix (Clopidogrel) / Xarelto (Rivaroxaban) / Eliquis (Apixaban) / Pradaxa (Dabigatran) / Warfarin

Do you take diabetic medication

YesNo

Please list all your regular medications belowInclude any non-prescription, over the counter medications, supplements or natural medications

Please list any allergies, and the reaction, below

13. COVID STATUS

Do you currently have, or have you recently tested positive for COVID?

YesNo

If yes, when did you most recently test positive?

If you currently have cold or flu symptoms, please call to change your appointment to a telehealth appointment.

OTHER COMMENTS

Please note any other comments below

PATIENT INFORMATION AND PRIVACY AGREEMENT

I agree that Dr Brown will take and document a full medical history as part of my routine medical care.
I consent to Dr Brown discussing details of my medical history with my general practitioner and other relevant medical specialists for the purpose of my ongoing medical management.
I consent to my medical records being recorded in an encrypted medical software accessible only to the practice of Dr Brown.
I consent that de-identified information relating to my diagnosis may be used for mandatory audit, teaching, and research. Independent ethics committee approval will be obtained where appropriate when used for research purposes.
I consent to de-identified clinical photographs or video to be collected in some cases as part of my medical record and may also be used for educational purposes.
I acknowledge that as an academic clinic, University of Sydney medical students may be present during my consultation with my consent.

By providing your e-signature, you agree to the terms outlined above *

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ELECTRONIC COMMUNICATION & MY HEALTH RECORD

I acknowledge that communication from the practice of Dr Brown via email may contain sensitive medical information.
Email correspondence involves the transmission of data via servers that may be located overseas.
I acknowledge that by consenting to electronic communication via email, some of my personal information will therefore be potentially stored on overseas email servers.
I acknowledge that the practice of Dr Brown will transfer all sensitive information received via email in a timely manner to my secure and encrypted medical record prior to deletion from email servers.

My Health Record is an Australian Government initiative where your healthcare information can be securely stored centrally for you to access, and be available to access by other authorised healthcare providers eg. your GP or in the event of an emergency. More information can be found at https://www.digitalhealth.gov.au/initiatives-and-programs/my-health-record

I agree to electronic communication via emailI DO NOT agree to electronic communication via email

I agree to have my correspondence from Dr Brown submitted to My Health RecordI DO NOT agree to have my correspondence from Dr Brown submitted to My Health Record

By providing your e-signature, you acknowledge you have understood the above *

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SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient / Guardian Signature *

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