Patient Health Record

Patient information and allergy records

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.

Could you please assist us by completing the following:

  • Title
     Mr Miss Mrs Ms
  • First Name*
  • Surname*
  • Date of birth*
  • Sex*
     Male Female

  • Medicare Card No.
  • Reference on Card.
  • Expire date.

  • Card Type
     Pension card Healthcare card Veteran's Affairs card
  • Type of Veteran's card
     Gold White
  • Card No
  • Expiry date

  • Cultural Background: Are you of Aboriginal or Torres Strait Islander origin?
     No Aboriginal Torres Strait Islander Aboriginal and Torres Strait Islander
  • Other cultural background
  • Country of birth

  • Is English your 1st language?*
     Yes No
  • If not, do you require an interpreter?
     Yes No
  • Please specify a language

  • Address*
  • Suburb*
  • Postcode*
  • If this is not your postal address, pleas supply your postal address

  • Home phone No.
  • Mobile
  • Wish to receive SMS?  Yes No
  • Email*
  • Occupation:

  • Emergency Contact Name
  • Relationship to Patient
  • Phone No.
  • Emergency Contact Name

  • Please leave this field empty.

This form has been designed to comply with RACGP Standards. Your doctor requires this information in order to ensure you receive the highest level of care possible. The information supplied on this form will be treated as confidential and with the utmost care for your privacy.