Patient registration Name* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Date of birth* MM slash DD slash YYYY Address Street Address Suburb State Post code Mobile phone* Home phone Work phone * Do you wish to receive automated SMS reminders? Yes NO Email* * Do you wish to receive correspondence by email? Yes NO Medicare No: Ref. No: (number next to name)Expiry: Private Health Fund: Membership No: DVA Card No: DVA Card colour: Next of kinName* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Date of birth MM slash DD slash YYYY Mobile phone* Home phone Work phone Health Records Collection StatementYour doctor is collecting your health information to provide you with health services. Please read and sign to give consent for your information to be collected and stored. Your medical information will be used for providing health care in the following way; To obtain medical history, diagnoses, organise medical test and provide treatment Disclosure to your doctor and/or other doctors involved in the provision of healthcare, this includes but not limited to writing correspondence and referral letters, organising medical tests and storing of reports provided to this practice by other doctors Administrative purposes in running this practice Billing purpose, including compliance with Medicare and Health Insurance Commision requirements Disclosure for research, teaching and quality assurance activities to improve healthcare Consent*I consent to the collection of my information by this practice for the purposes set out as above. Yes No Name First Last Signature*Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.