Margaret River Surgery 08 9757 2766 book online
Cowaramup Surgery 08 9755 9777 book online
Patient Feedback Order Repeat Prescriptions Online

Home
About
Services
COVID-19
Appointments
Fees
Contact

New Patient Registration

New Patient Information Form

Please assist us by completing the new patient record form with complete and accurate information

Step 1 of 8

12%

Contact Information
Name*
Title First Surname
Date of Birth*
MM slash DD slash YYYY
Email*
Phone*
Mobile*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Postal Address
- Same as above
Postal Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bank Account Details
Your bank account details are required for Medicare refund purposes
Account Name BSB Account No

Cultural Identity
To assist with health initiatives - are you Aboriginal and/or Torres Strait Islander?*
Your Nationality/Cultural Background*
Do you require an interpreter service?*
Language spoken

Medicare number*
Line number (Next to your name)*
Expiry date*
MM slash DD slash YYYY
Centrelink Health Care Card or Pension number
Expiry date
MM slash DD slash YYYY
DVA number
Gold or White
Expiry date
MM slash DD slash YYYY

Emergency Contact Details
Emergency Contact Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Relationship to you*
Phone*
Mobile*

Next of Kin
Next of Kin Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Relationship to you*
Phone*
Mobile*

Your Health Information
Allergies*
Do you have any allergies or are you sensitive to drugs or dressings
If yes, provide details*
Medication*
Are you taking any medication?
Please list all your current medications, including vitamins & over the counter meds*
Medical History*
Do you have or have you had a history of the following?
- Surgery
- Asthma
- Diabetes
- High blood pressure
- Chronic Illness
- Mental Health
- Hepatitis A, B or C
- Other
- None
Provide details*
Lifestyle Risk Factor Information
Smoking*
Do you smoke?
If yes, how may a day / week?*
If yes, how old were you when you started?*
Are you interested in quitting smoking?*
How old were you when you gave up smoking permenantly?*
Alcohol*
Do you drink alcohol?
If yes, how many units per day / week / month?*
Family Health History Information
Have any members of your family have:*
- Heart Disease
- Asthma
- Diabetes
- High blood pressure
- Mental Illness
- Cancer
- Other significant
- None
Please provide details*

Patient Consent
When you register as a patient of our practice, you provide consent for our GP’s and practice staff to access and use your personal information so they can provide you with the best possible healthcare. Only staffs that need to see your personal information will have access to it under privacy and confidentiality restraint. If we need to use your information for anything else we will seek additional consent from you to do this. Why do we collect, use, hold and share your personal information? Our practice will need to collect your personal information to provide healthcare services to you. Our main purpose for collecting, using, holding and sharing your personal information is to manage your health. We also use it for directly related business activities such as medical claims and payments, practice audits and accreditation purposes, and other business processes for example, Doctor, nurse and staff training.
- I give permission for my personal information to be collected used and disclosed as described above including contact by SMS & Email.
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Δ

General Practice
Acupuncture
Men’s Sexual Health
Obstetrics
Occupational Health
Pathology
Physiotherapy
Preventative Health
Skin Clinic
Travel Medicine

Have a Question? Get in Touch with us Today Contact Us

Opening Hours

Margaret River Surgery
1 Station Road, Margaret River, WA 6285

Monday to Friday:: 7:30am – 5:30pm
Saturday:: 8:30am – 12:30pm

Cowaramup Surgery
33 Bussell Highway, Cowaramup, WA 6284

Weekdays:: 8:30am – 5:30pm

Margaret River and Cowaramup Surgery
Copyright © 2023 All Rights Reserved

Proudly created by Brandicoot