Margaret River Surgery
08 9757 2766
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Cowaramup Surgery
08 9755 9777
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Switzerland
Syria
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Thailand
Timor-Leste
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Tokelau
Tonga
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Turkey
Turkmenistan
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Tuvalu
US Minor Outlying Islands
Uganda
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Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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Postal Address
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Postal Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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?
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No
Yes – Aboriginal
Yes - Torres Strait Islander
Yes - Aboriginal and Torres Strait Islander
Your Nationality/Cultural Background
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Do you require an interpreter service?
*
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No
Yes
Language spoken
Medicare number
*
Line number (Next to your name)
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Expiry date
*
Date Format: MM slash DD slash YYYY
Centrelink Health Care Card or Pension number
Expiry date
Date Format: MM slash DD slash YYYY
DVA number
Gold or White
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Gold
White
Expiry date
Date Format: MM slash DD slash YYYY
Emergency Contact Details
Emergency Contact Name
*
First
Last
Address
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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
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No
Yes
If yes, provide details
*
Medication
*
Are you taking any medication?
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No
Yes
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?
-select-
Yes
No
Ex-smoker
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?
-select-
Yes
No
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.
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Margaret River
Cowaramup