New Patient Registration Form

Please, make sure you have contacted us to book an appointment before you fill out the below new patient registration form.

Have you booked an appointment?

Patient Information

Title

First name

Surname

Date of birth

Gender

Street Address

Suburb

State

Postcode

Email Address*

Contact Number

Interpreter Required?

Yes No

Preferred Language

Ethnicity?

Aboriginal/Torres Strait Islander

Yes No Both

Occupation?

Medicare Details I do not have a Medicare number

Medicare Card?

Card reference number (number next to name)

Expiry

Do you have a health care card?

Yes No Unsure

Health care card type

Membership Number

Expiry

Health Insurance Details

Do you have private health insurance?

Yes No Unsure

Health Fund

Membership Number

Medical Information Are there any medical conditions that we should be aware of, such as:

Do you have diabetes?

Yes No

Do you have high blood pressure?

Yes No

Other conditions:

Do you take regular medication?

Yes No

If yes, please list below:

Do you have any allergies?

Yes No

If yes, please list below:

Emergency Contact (friend or relative)

Name

Relationship to applicant

Street Address

Suburb

State

Postcode

Phone (Home)

Mobile

Next of Kin (friend or relative) Same as Emergency contact

Name

Relationship to applicant

Street Address

Suburb

State

Postcode

Phone (Home)

Mobile

Reminder Consent:

Do you consent to TLC Primary Care calling/texting to remind you about your appointment?

Yes No

Do you consent to TLC Primary Care telling someone about your appointment time? (You can change this at any time)

Yes, I consent to TLC Primary Care sharing my appointment times with:

No, I do not want TLC Primary Care to share my appointment time with anyone else

Security*

New Patient Registration Form

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