Home - Corriest Medical Clinic

Are you completing this form on behalf of a child under the age of 17? *

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Yes

Patient Details

Title*

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Gender*

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First Name*

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Last Name*

Known as

Date of Birth*

Do You identify as:

Aborginal

Torres Strait Islander

Address Details

Address Line 1*

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Address Line 2*

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Subrub*

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State*

Post Code*

Country*

Do you have a different postal address?

Please check this box if your postal address is different to your home address.

Postal Address

Address Line 1*

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Address Line 2*

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Subrub*

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State*

Post Code*

Country*

Contact Details

* Phone Numbers (please enter at least one)

Home

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Work

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Mobile

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Email

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Do you consent to receiving Emails? *

Yes

No

Do you consent to receive SMS appointment remainders?*

Yes

No

Next of Kin Details

Next to Kin (NOK) *

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Relationship to Patient *

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* Phone Numbers (please enter at least one)

Home

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Work

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Mobile

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Medicare and Concession Card Information

Do you have a Medicare card? *

No

Yes

Medicare Card No

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Reference Number

Expiry Date*

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Payer's Medicare Details

As the patient is under 17 years of age, please provide the payer's Medicare details:

Name*

Reference No (next to name)*

Date of Birth*

Concession Type: *

Pension Card

Aged

DVA - Gold Card

DVA - White Card

Health Care Card

None

By becoming a patient of Corrie St Medical Clinic and signing this new patient form, I agree and consent to the following:

I consent to the use of my personal health information by the Corrie St Medical Clinic and other health care providers involved in my medical treatment and health care with this Centre.

I consent to the disclosure of my personal health information by the above-named practice to other health care providers involved directly or indirectly in my personal health care or medical treatment.

I consent to receive follow up reminders and recalls sent via SMS or mail to my contact details as part of preventative health services offered by this practice when routine investigations are due.

I understand that a minimum of 2 hours’ notice to cancel or reschedule an appointment is required to avoid a fee.

I understand that Schedule 8 scripts will not be prescribed at my initial appointment.

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New Patient Form

Patient Details

Address Details

Postal Address

Contact Details

Next of Kin Details

Medicare and Concession Card Information

Payer's Medicare Details

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