New Patient Registration Form

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+61 8 9493 7700

First Name

Last Name

Date of Birth

Address

Street Address

Suburb

State

Postcode

Country

Contact Number (Home)

Contact Number (Mobile)

Email Address

I give consent for the practice and doctor to communicate with me by e-mail, including attachments of letters and results (required)

Yes No

Occupation

Marital Status

Medicare Number

Ref

Expiry

Pensioner Number

Expiry

DVA (Vet Affairs) Number

Gold White

Private Health Fund

Membership Number

Do you have hospital cover with your private health insurance?

Yes No

Usual GP (if different from the referring Doctor)

GP Contact Details

Emergency/ Next of Kin Contact — Name

Phone Number

Email Address

Relationship To You

Do you already have a GP referral?

Yes No

Upload GP letter

Max. file size: 50 MB, Max. files: 3.

Emergency contact

Name

Relationship to you

Address

Suburb

State

Postcode

Home phone number

Mobile

Parent / guardian / Next of kin (if different to above)

Relationship to patient

Address

Home number

Mobile

Patient Consent & Privacy Act

The Privacy Act of 1988 requires medical practitioners to obtain patient consent to collect, use and disclose their personal information. The practice staff and medical practitioners may participate in the collection of information required to treat and advise you. This includes: Full medical history, family medical history, ethnicity, genetic information, contact details; Medicare/private health fund, billing and account details, information obtained from other sources, for example, (1) Other doctors (current or former), allied health professionals, dentists, hospitals and day surgery units, or (2) Relatives or other sources, in emergency situations where we cannot obtain your prior express consent.

Financial Consent

GeriMed WA operates as a private billing practice. All consultation invoices are to be paid on day of appointment and can be sent to Medicare for rebates.

Consent

I provide my consent for GeriMed WA to collect, use and disclose my personal information as outlined above.
I understand that I am entitled to access my own health records except where access would be denied as outlined above.
I authorise the disclosure of all past and present protected health information requested by GeriMed WA from health care professionals, hospitals or organisations.
I understand that I may withdraw my consent as to use and disclosure of my personal information (except when legal obligations must be met).
I understand the fee structure and agree that I am responsible for full payment of account fees, on the day of the consultation or prior to the consultation.

By ticking this box and typing your name below, you acknowledge and agree that this typed name will serve as your digital signature and carry the same legal weight and implications as a handwritten signature.(Required)

I consent

Name (First and Last)(Required)

Today's Date (Required)

Reminder: Every new patient appointment requires a Referral from a GP, which can be emailed to admin@gerimedwa.com.au or completed by a GP online here