Please Complete the form below. Title*Mr Mrs Miss Ms Master DrMx Surname* Middle Initial First Name* Date of Birth* Sex Assigned at Birth*MaleFemalex Gender Identity*MaleFemalex Known As Address (address and contact details will be used for appointment and health reminders) Address* Suburb* Postcode* Postal Address*WRITE AS ABOVE IF SAME AS RESIDENTIAL Postal Suburb*WRITE AS ABOVE IF SAME AS RESIDENTIAL Postal Postcode*WRITE AS ABOVE IF SAME AS RESIDENTIAL Contact Mobile Number* Work Number Email* Marital Status Occupation Country of Birth and Ethnicity* Aboriginal or Torres Strait Islander*YesNo Consent to SMS Communication*YesNo Cultural /Sexual /Religious BackgroundIS THERE ANYTHING WE SHOULD KNOW THAT WILL ENABLE OUR PRACTICE TEAM TO REMAIN RESPECTFUL AND CONSIDERED DURING YOUR HEALTH CARE VISIT ? Medicare Card number* Reference number (next to patients’ name)* Expiry Day* Pension/Health Care/DVA Cards Card (Please Check)PensionHealth CareDVA Card number Expiry Day Next of Kin (Required) Next of Kin Relationship to Patient* Is Next of Kin an Existing Patient?*YesNo Next of Kin Title*Mr Mrs Miss Ms Master DrMx Next of Kin Surname* Next of Kin First Name* Next of Kin Known As Next of Kin Date of Birth* Next of Kin Gender*MaleFemalex Next of Kin Contact Next of Kin Address* Next of Kin Suburb* Next of Kin Postcode* Next of Kin Mobile* Next of Kin Work Number Emergency Contact (If Different to next of Kin) Emergency Contact Relationship to Patient Is Emergency Contact an Existing Patient?YesNo Emergency Contact TitleMr Mrs Miss Ms Master DrMx Emergency Contact Surname Emergency Contact First Name Emergency Contact Mobile Emergency Contact Work Number/Home Number Medications Please list your current medications and the conditions they relate to, including vitamins and natural medicines. Medication , Condition, mg/ml, Frequency How did you hear about The Hills Medical? FamilyFriendHotDocWalk in/drive by/local InternetAdvertisingOther I acknowledge I have read and understood The Hill Medical : Transfer of Health Information, Remind & Recalls, Payment and Cancellation Polices*Policies Accepted – Read The Hill Medical : Transfer of Health Information, Remind & Recalls, Payment and Cancellation Polices Submit
