New Patient Form | Greenslopes Obstetrics & Gynaecology

Title*

First Name*

Surname (as per Medicare card)*

Date of Birth*

How did you hear about us?*

Other

Address*

Street Address City State Postcode

Telephone - Mobile*

Telephone - Home

Telephone - Work

Email*

By providing your email you are agreeing to receive correspondence regarding your medical care.

Occupation

Medicare / Health Fund

Medicare No.*

Ref No. (# next to your name)*

Expiry Date*

Private Health Fund

Are you in a Health fund wait period

Yes
No

Membership No.

No Private Health

Please confirm

I confirm that I do not have Private Health

Dept of Veterans Affairs No.

Next of Kin Details

Next of Kin Name

Next of Kin Contact Number

Next of Kin Relationship

Partners Name

Partners Contact Number

Partners Occupation

GP Details

Usual GP's Name

Clinic

Your personal details

Allergies

Weight (kg)

Height (cm)

Country of Birth

Have you had any recent scans or pathology done in relation to the purpose of your appointment today?

Recent Pathology?

Yes
No

If Yes, where?

i.e. SNP, QML, Mater Pathology

Recent Scans?

Yes
No

If Yes, where?

i.e. QScan, QueenslandXRay, Savage Xray

I ACKNOWLEDGE there may be additional fees for anaesthetic, radiology, pathology services which are separate from GOG, and these services will be billed separately by the service provider/s concerned. I consent to you arranging these services as part of my care. Please call SNP 3377 8747 or QML 3121 4444 to check your pathology fee’s.

Patient Consent

Due to the Federal Privacy Act (2001), Greenslopes Obstetrics and Gynaecology requires your consent to collect personal information about you.

Please read this information carefully and sign where indicated below.

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and full medical history so that we properly assess, diagnose, treat, and be proactive in your health care needs. In addition we will use information you provide in the following ways:

Administrative purposes in running our medical practice.
Billing purposes, including compliance with medical and health insurance commission requirements.
Sharing of information with other health practitioners involved in your care, including treating doctors and specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and the reports/results returned to us following the referral.
Notification to Queensland Health of certain diseases as required by Law.

Please confirm the following:

CAPTCHA

Please be advised that you are not required to complete any additional forms at this time.

Phone

This field is for validation purposes and should be left unchanged.

Patient Registration & Consent Form

If you are a new patient, you must complete the form below prior to your first appointment.