Medical Form

Patient Name (required)

First

Middle

Last

Preferred Name

Title (required)

Other Detail

Gender (required)

Address (required)

Suburb (required)

State (required)

Postcode (required)

DOB (required)

Best Contact Number (required)

Email (required) please enter email provided to reception Please add a valid email!

Aboriginal or Torres Strait Islander? (required)

Cultural background

Is English your first language?

If no, is an interpreter required?

Name (required)

Relationship (required)

Phone (required)

Are you under 16? (required)

Yes

No

Medicare No

Ref

Expiry

NB FOR PATIENTS UNDER 16, WE REQUIRE PARENT OR LEGAL GUARDIAN MEDICARE DETAILS FOR CLAIMING

PARENT Medicare No

Ref

PARENT DOB

Do you have Private Hospital Cover?

Yes

No

Name of Health Fund

Membership No

Other Health Fund Name

Is this Overseas Travel or Student cover?

Yes

No

Do you have a Department of Veteran Affairs Card (DVA)?

Yes

No

DVA No

Colour

Condition

Do You Have Pension/Health Care Card?

Yes

No

Pension/Health Care Card No

Expiry

Is this a Workcover Claim?

Yes

No

Workcover Claim No

Employer

Referring Doctor (required)

Referring Date (required)

Is the referring doctor your usual GP?

Yes

No

Usual GP (if not referrer)

Usual GP Practice

Other Treating Practitioners

Do You Currently Take Any Medications?

Yes

No

Are the details included accurately on your referral?

Yes

No

Please list all current medications including aspirin, over the counter, herbal or vitamin preparations

Do You Have Any Medical Conditions?

Yes

No

Are the details included accurately on your referral?

Yes

No

Do you have a history of any of the following? (Please tick all that apply)

Asthma

Blood clots

Excessive bruising

Heart problems

Bleeding disorders

Diabetes

Headaches

Other (please list below)

Do You Have Known Allergies or Reactions?

Yes

No

Are the details included accurately on your referral?

Yes

No

Have you ever had previous reaction to any of the following? (Please tick all that apply)

Anaesthetics

Aspirin

Antiseptic lotion/cream

Sulphur

Adhesive tapes

Local anaesthetic agent

Other(please list bellow)

Are you a smoker?

Do you drink alcohol?

Cigarettes/cigars per day:

Drinks per week:

Are you a smoker?

Cigarettes/cigars per day:

Do you drink alcohol?

Drinks per week:

At CompleteENT we value the doctor-patient relationship and acknowledge that patient privacy is vital. The Privacy Act 1988 and its recent amendments formalised the already existing and acknowledged privacy obligations of our practice.
You are required to consent to the collection of your personal information, and for its use in the following ways:

Administrative and billing purposes, including compliance with Medicare requirements.
Disclosure of information to other healthcare workers involved in your healthcare for the purpose of patient care and teaching.
Use of de-identified healthcare data for the purposes of research and quality assurance activities to improve individual and community health care and practice management.
To comply with any legislative or regulatory requirements, such as notifiable disease reporting.
At the request of our medical defence organisation, Avant Mutual Group. If you wish to know whether your health information is held by this organisation you may write to: PO Box 746, QVB NSW 1230.
For reminders and recalls which may be sent to you regarding your healthcare and management.

Patients who wish to look at their information held by this practice or who may have queries about privacy of information are welcome to discuss these matters with their treating doctors. You can assist in maintaining the accuracy of your information by advising the practice of any changes to your personal contact details. You can request a copy of the CompleteENT Privacy Policy, or visit our website www.completeent.com.au for further details about the collection, use and disclosure or your health information.

By ticking the box below, you consent to the handling of your information by CompleteENT for the purposes set out above

I Consent to the handling of my information as above
(Guardian to complete if patient under 18 years)

Print Name (required)

Todays Date

Payment is required on the day of consultation.
Eftpos facilities are available and we can process your claim through to Medicare for you to receive a rebate to your bank account.
For information regarding billing arrangements for associated services from allied health practitioners such as pathology and radiology, these details should be sought directly from the health provider for the service.
Please discuss any queries concerning financial arrangements with your doctor.

This practice may send appointment reminders, recall reminders and messages via SMS and/or email
By ticking the boxes below, you consent to CompleteENT communicating with you via SMS and/or email
We will not send you any advertising material or spam, we will only communicate with you regarding your healthcare

SMS communication

Email communication

How did you find out about CompleteENT?

Other marketing Avenue
Please Specify

Patient Registration

PERSONAL DETAILS

NEXT OF KIN DETAILS

NB FOR PATIENTS UNDER 16, WE REQUIRE PARENT OR LEGAL GUARDIAN MEDICARE DETAILS FOR CLAIMING

REFERRAL DETAILS

MEDICATIONS

MEDICAL CONDITIONS

ALLERGIES

SOCIAL HISTORY

SOCIAL HISTORY

PRIVACY CONSENT