Patient Registration Name First Name Last Name Date of Birth: MM DD YYYY Gender: Male Female Other Home Phone (###) ### #### Mobile Phone (###) ### #### Email * Residential Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact Name * First Name Last Name Relationship: Phone (###) ### #### Medicare Details Medicare Number Individual Ref. No: Expiry Date: (DD/MM/YYYY) Name of Cardholder (if different): Private Health Insurance Information (If applicable) Health Fund Provider: Policy Number: Membership Number: Policy Holder Name (if different): Medical History 1. Do you have any known allergies? Yes No If yes, please list: 2. Are you currently taking any medications? Yes No If yes, please list: 3. Do you have any chronic conditions? Yes No If yes, please list: 4. Have you had any previous surgeries related to gastroenterology? Yes No If yes, please list: 5. Family History (if applicable): Yes No If yes, please list: Usual General Practitioner (GP) Details (If applicable) GP Name First Name Last Name Clinic Name Phone (###) ### #### Fax Number (if applicable) Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country Consent and Acknowledgment - I consent to the collection of my personal and medical information as required for the purposes of medical treatment and care. - I acknowledge that the information provided above is accurate and complete to the best of my knowledge. - I understand that the clinic may need to verify my Medicare and health insurance details, and I consent to this process. - I acknowledge that the clinic uses software to temporarily record consultations for the purpose of using voice-to-text technology to prepare medical notes. Name First Name Last Name Date MM DD YYYY Thank you!
