Hope Island Medical Centre

New Patient Form

Welcome to our practice. For information regarding our services and opening hours please ask our reception staff for the practice information booklet.
We are committed to providing our patients with the best care, to do this it is essential that your medical records are up to date and accurate. This information is kept strictly confidential.

Patient Details

Title *

Other title if any

Sex *

Given Names *

Surname *

Known As

Date of Birth *

Do you identify as being: *

Medicare Number

Patient #

Expiry Date

DVA Number

Expiry Date

Type of DVA card

Pension/Health Care Card Number

Expiry Date

Private Health Care

Fund Name

Street Address *

Suburb *

Post Code *

Postal Address is same as Residential

Postal Address *

Suburb *

Post Code *

Home Phone

Work Phone

Mobile Phone *

Email *

Marital Status *

Occupation

Country of Birth

Year of Arrival

Do you identify as from a culturally diverse and/or non-English speaking background?

Other Religious, Cultural

Ethnicity

Previous GP Name

Previous GP Address

Patient Health Information Consent Form

Our practice values the privacy and security of your personal information collected to provide you with the best care. Personal information is managed in line with the Privacy Act 1988 and the Australian Privacy Principles. For more information about our Privacy Policy please ask a receptionist or review our webpage.

What we collect and store:

Name, date of birth, address, contact details, next of kin, gender
Medical information including medical history, medications, allergies and reactions, immunisations, social history, risk factors, family history
Medicare / DVA/ Concession card
Information from other people who are providing care (e.g. specialists) and;
any other information to meet your health needs.

Your medical and personal information may be used and shared to support your healthcare needs for the following reasons:

Other healthcare people such as our staff, treating doctors, specialists and allied health professionals visiting the practice or external
To run our practice (e.g. Medicare billing, accreditation companies, I.T people)
When it is required by law (e.g. notifiable diseases, court order)
Students (such as medical/nursing/allied health) in this practice
Other people (e.g. your guardian, power of attorney, carer) and;
Updating national registers such as immunisation and cancer screening.

Your contact details may be used to remind you of appointments and/or the need to return for follow up with our clinic (examples: health checks, follow up on results, immunisations)

An SMS/ letter or telephone call to remind you of appointments/ or need to return for follow up with our clinic

Your de-identified information is used for, or by:

Quality Improvement activities at the practice
Accreditation
Students and staff to participate in medical training/teaching.
Gold Coast Primary Health Network to inform local health needs and services and;
research purposes.

I AGREE for my de-identified information to be used for the above reasons. Either choice will not affect how we care for you

I give my permission for my personal contact and health information to be collected, used and disclosed as indicated as per my choices above. I can change my mind at any time. I will tell the practice if this happens.

If you're filling this out on behalf of the patient, fill out your name below:

Your relationship to Patient:

Next of Kin

Name *

Date of Birth *

Relationship to you *

Street Address *

Suburb *

Post Code *

Home Phone

Work Phone

Mobile Phone *

Emergency Contact is same as next of kin

Emergency Contact

If you ticked the box to have your emergency contact the same as your next of kin, The below will autofill.

Name

Date of Birth

Relationship to you

Street Address

Suburb

Post Code

Home Phone

Work Phone

Mobile Phone

Patient Medical/Health History

Name *

Date of Birth *

Reminder System:
Our practice provides our patients with preventive care and early case detection reminders, eg. immunusations, annual health checks, skin checks and cancer screening. We contact you about these important health reminders as part of the service we provide, via telephone, Hotdoc SMS, Weko SMS or letter

Please check the box if you do not wish to be part of our reminder system and discuss this with your GP

If we need to contact you what is your preferred method of contact:

Phone

Mail

SMS

Do you have any allergies or are you sensitive to drugs or dressings? *

If you selected "Yes" to the previous question, please specify here:

Family History

Have any of your family members had any any of the below?

Diabetes

Asthma

Heart Disease

Mental Illness

Cancer

Social History

Tobacco

Alcohol

Drugs

Do you have a history of?

Operations

Asthma

Diabetes

Hypertension

Chronic Illness

Other

Current Medications

Current Medications include over the counter medications, vitamins and minerals.

Cholesterol: When was the last time you had a cholesterol check?

Cholesterol: What was the level (if known)?

Blood Pressure: When was the last time your blood pressure was taken?

Sun Protection

How often do you use the following to protect yourself from the sun when outdoors?

Protective Clothing *

Sunscreen Creams *

New Patient Form

Patient Details

Patient Health Information Consent Form

Next of Kin

Emergency Contact

Patient Medical/Health History

Family History

Have any of your family members had any any of the below?

Social History

Do you have a history of?

You have not selected your gender.

Please go back to the start of the form and select your gender.

Females

When did you last have?

Cervical Screening (Pap Smear)

Breast Check

Mammogram

Skin Check

Males

When did you last have?

An Overall Checkup

A Prostate check

Skin Check

Sun Protection

How often do you use the following to protect yourself from the sun when outdoors?

Hope Island Medical Centre

10 Santa Barbara Road Hope Island QLD 4212

PH: (07) 5510 8199

Fax: (07) 5510 8399

New Patient Form

Patient Details

Patient Health Information Consent Form

Next of Kin

Emergency Contact

Patient Medical/Health History

Family History

Have any of your family members had any any of the below?

Social History

Do you have a history of?

You have not selected your gender. Please go back to the start of the form and select your gender.

Females

When did you last have?

Cervical Screening (Pap Smear)

Breast Check

Mammogram

Skin Check

Males

When did you last have?

An Overall Checkup

A Prostate check

Skin Check

Sun Protection

How often do you use the following to protect yourself from the sun when outdoors?

Hope Island Medical Centre

10 Santa Barbara Road Hope Island QLD 4212

PH: (07) 5510 8199

Fax: (07) 5510 8399

You have not selected your gender.

Please go back to the start of the form and select your gender.