(02) 4474 2200

Moruya Medical Centre: New Patient Information Record

Dear Patient,

PLEASE PRINT OUT, COMPLETE & BRING FORM INTO THE MORUYA MEDICAL CENTRE.

In the interests of comprehensive & effective patient care it is extremely important that the information we hold in your medical record is as accurate as possible. Our practice collects this information for the primary purpose of providing quality health care.We require you to provide us with your personal details & a full medical history to allow us to properly access, diagnose, treat & advise on your health care needs.

Please be reassured that all information given on this document becomes part of your medical record & therefore is kept strictly confidential & only accessible by your doctor &/or appropriately authorised clinical staff members.

Moruya Medical Centre requires your consent to collect information about you. Please tick the applicable boxes & sign for consent at the end of this form.

Please complete the sections that you believe to be relevant to your health care. Filling out this document is purely optional & you are under no obligation to fully complete. Please hand to your doctor in your appointment.

 

  • Contact Details:
  • Title *
  • Firstname *
  • Surname *
  • Date of Birth *
  • Primary Phone Number *
  • Email address
  • Address *
  • Postal Address *
  • Secondary Phone Numbers *
  • Occupation
  • Emergency Details
  • Allergies *
  • Next of Kin &/or Emergency Contact *
  • Medications *
  • Additional useful details
  • Marital Status
  • Sexual Orientation
  • Ethnicity/Cultural Background
  • Sporting activities, interests, hobbies & pets
  • Are you Aboriginal? *
  • Are you Torres Strait Islander? *
  • Medical History
  • Family Medical History *
  • Smoking
    please indicate amount ie how many per day
  • Alcohol Consumption *
    please indicate how many/day & how many days/week
  • Drug usage-optional
  • Children
    Insert names & year of birth
  • Additional Notes

I give consent for my personal health information to be used for administrative purposes to assist in the running of Moruya Medical Centre, including disclosure to others involved in my healthcare, such as Doctors/Specialists within & outside of this Practice. This may occur through referral to other Doctors, for medical tests & in the reports/results returned to my GP following referral.

Yes                                        No

I give consent for disclosure for research & quality assurance activities to help gain information that will provide better health outcomes & care for our patients. This may occur where the Practice is involved in a quality improvement project, & may involve de-identified patient information to be transferred to a third party.

Yes                                        No

I give my consent to be part of the Practice's National, State & Territory reminder systems.

Yes                                        No

I give consent to the presence of a third party to be present during my consultation; this may include a nurse, medical student, family member or friend, Centrelink or Workcover representative.

Yes                                       No

Once you have signed below the consent will be noted in your clinical record. The consent continues indefinitely unless you choose to withdraw it. If at any time you want to withdraw this consent you have the right to do so. Withdrawal of consent is available for you to sign, please ask the Admin team about the forms.

I acknowledge & understand that the phone numbers I provide may have voice messages left on them & my name will be called out in the waiting room.

Signed.............................................................           Date.................................................

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