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Patient Registration Form

Date

Today's Date

Title

Mr Mrs Ms Miss Mx Other

Please select your title

If you ticked 'Other' please specify

Eg; Dr, Prof, Sr etc...

Given Name (s)

Please write Given Name (s) as shown on your Medicare/Health Insurance card

Preferred Name

Surname

Please write surname as shown on your Medicare/Health Insurance card

Date of Birth

Date you were born

Birth Sex

Male Female

Gender

Male Female Other

If you ticked 'Other' please specify

Pronouns

She/Her/Hers He/Him/His They/Them/Theirs

Ethnicity

Are you Aboriginal/Torres Strait Islander?

Country of Birth

Preferred Language

Interpreter Needed?

Yes No

Residential Address

Must be current

Postcode

Postal Address (If different from above)

Address where you would like future correspondence posted

Postcode

Home Phone

If you don't have a home phone number, please just put your mobile number

Mobile Phone

Email

Medicare Number

Please enter Medicare Number

Ref No #

Enter number you appear on your Medicare

Expiry

Date card expires

Do you have a Healthcare/ Pension or DVA Card

Health Care/Pension or DVA Card Number

Expiry

Date Health Care / Pension / Veterans Card Expires

IHI number

(Individual Healthcare Identifier) For international students only

Allianz (OSHC) Card Number

For international students only

Medibank Card Number

For international students only

Bupa Card Number

For international students only

NIB Card Number

For international students only

Other Card

For international students only

Are you a Berwick Federation / Chisholm Student

Yes No

Occupation

Next of Kin

Next of Kin Given & Family Name

Next of Kin Phone Number

Relationship

What relationship does your Next Of Kin have with you? mother? husband? etc..

Emergency Contact (not living with you)

Emergency Contact Given & Family Name

Emergency Contact Phone Number

Relationship

How did you hear about us?

If you ticked 'Other' please specify

What influenced your choice of clinic

If you ticked "Other' please specify

I GIVE CONSENT TO RECEIVE THE FOLLOWING ELECTRONIC REMINDERS / MESSAGES

Appointments Clinical Reminders Clinical Communications ( Results & Clinical Messages) Health Awareness (Leaflets & Database Search)

By Communicating electronically with Berwick Healthcare, I dismiss the practice from all claims, losses, expenses and liabilities caused by any problems in using electronic mail with the risk of interception by third parties and non-recipients.

I agree

I agree to have my details saved

Email address

On campus with Federation university

Postal Address: PO Box 827, Berwick 3806 Location: 76 Clyde Road, Berwick Vic 3806 Phone: (03) 97961500 Fax: (03) 97961300 Email: reception@berwickhealthcare.com.au

My Healthcare Rights

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