New Patient Form

Please fill in the online form below with your details.

Personal Details

Title *

First Name *

Last Name *

Preferred Name

Gender *

Male

Female

Date of Birth *

Day

Year

Month

Address *

Suburb *

Postcode *

Mobile Phone *

Home Phone

Work Phone

Email Address

In order for us to tailor optimal and appropriate medical care

Do you identify yourself as Aboriginal? *

Yes

Do you identify yourself as Torres Strait Islander? *

Yes

Do you identify as someone from a culturally and/or linguisitically diverse background? *

Yes

If yes, what is your ethnicity?

What is your country of birth?

Do you require a translator?

Yes

Language

Medical Information

Medicare Number

Ref

Exp

DVA Number

DVA Type

Gold

White

Pension/Health Care Card No

Ref

Exp

Individual Health Identifier Number

Next of Kin (in case of emergency)

Name *

Relationship *

Contact Number *

Address

How did you find out about us?

Please select

Referred by

Name

Other

Appointment Reminders, Messages & Emails

You may be sent an SMS Message reminding you of your appointment time. Please advise reception staff if you do not wish to receive SMS reminders, any other messages or emails.

Privacy Statement

The Midtown Medical Clinic is committed to maintaining the confidentiality of your personal health information. Your medical record is a confidential document. It is policy of this Practice to maintain security of personal health information at all times and to ensure that this information is only available to authorised members of staff. We have a more comprehensive Privacy Act Policy that you are welcome to read upon request.

I accept this privacy statement *

Yes

Cancellation Policy

Failing to attend your appointment or multiple late cancellations may incur a cancellation fee.

I accept this cancellation policy *

Yes

Payment Policy

Full payment is required at the time of consultation. Cash, EFTPOS and credit cards are accepted. Work Cover and TAC patients are charged private fees and can claim the cost of consultations back from their Employer, Work Cover Insurer or TAC. In some situations, this may result in a gap between our fees and the amount refunded by the Employer, Work Cover Insurer and TAC. Outstanding accounts referred to our debt collecting service will incur a debt collection fee.

I accept this payment policy *

Yes