New Patient Registration

Personal Details

Please note: items marked * indicate mandatory fields.

Title*

First Name*

Last Name*

Preferred Name

Occupation

Date Of Birth*

Parent/guardian details if patient is under 16 years

Full Name

Date Of Birth

Position on Medicare card (example 1)

Contact Details

Please note: items marked * indicate mandatory fields.

Address*

Suburb*

State*

Postcode*

Is this your postal address?*

Yes No

Postal Address*

Suburb*

State*

Postcode*

Email*

Home Phone

Work Phone

Mobile Phone*

Preferred Contact Method*

Medicare/Insurance Information

Please note: items marked * indicate mandatory fields.

Medicare Number

Medicare IRN

(1 digit next to cardholder's name)

Valid To

Private Health Fund Name

Private Health Fund Number

Have you been a member of this health fund for more than 12 months?

Yes No

Are you a member of the Department of Veterans Affairs (DVA)? *

Yes No

Department of Veterans Affairs (DVA) Member Number*

DVA Card Level*

Emergency Contact

Please note: items marked * indicate mandatory fields.

Next of kin Name*

Next of kin Phone*

Relationship to next of kin

Medical Information

Please note: items marked * indicate mandatory fields.

Usual GP*

Usual GP Contact Phone Number*

Existing, diagnosed conditions

Previous operations

Current Medications (Including over the counter medications)

Current Vitamins or Dietary Supplements

Allergic reactions (Drugs or other causes)

Height (cm)

Weight (kg)

Social History

Do you smoke or vape? How many per day/week? Date ceased or never

Drink alcohol? How many per day/week/month or never

Drug use? Type and frequency or never

Family History

Has any member of your family had any of the following?

Cancer Other

Please explain

Other current Doctors/Specialists/Allied health

None 1 2 3 4

Specialist Name (1)

Specialty (1)

Specialist Medical Practice Name (1)

Specialist Phone (1)

Specialist Name (2)

Specialty (2)

Specialist Medical Practice Name (2)

Specialist Phone (2)

Specialist Name (3)

Specialty (3)

Specialist Medical Practice Name (3)

Specialist Phone (3)

Specialist Name (4)

Specialty (4)

Specialist Medical Practice Name (4)

Specialist Phone (4)

Consent to release medical information* I give my consent to Dr Xavier Moar, or his agents and advisors, to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information to Dr Xavier Moar, or his agents and advisors, as may be requested. This is in line with the National Privacy Act updated 1st November 2010. For more information view our Patient Information Privacy Statement.

Yes, I consent to the above