New Patient Form - Collaborative Healthcare

Please note: Dr Costigan is currently not accepting new patients

Contact Information

Title

First Name*

Surname*

Date Of Birth*

Email*

Gender*

Male
Female
Other

Address*

Street Address City Post Code

Postal Address

If different from above

Street Address City Post Code

Mobile Phone*

Home Phone

Occupation

Preferred Contact Method

If we need to contact you what is your preferred method of contact?

Mobile Phone
Home Phone
Mail

Appointment Reminders

Do you consent to receive appointment reminders via SMS

Yes
No

Healthcare Identifiers

Medicare Number

Ref

Expiry

Private Healthcare

Yes
No

Membership Number

Health Fund Name

Dept Vet Affairs Card

Yes
No

Dept. of Veterans’ Affairs File Number

Card Colour

Gold
White

Concession Pension/Health Care?*

Yes
No

Card Number

Concession Expiry

Next Of Kin

Name

Relationship to You

Home Phone

Mobile Phone

If the patient is a child, is there currently any court orders in place relating to custody we should be aware of?

Yes
No

Seperate Emergency Contact Details?

Yes
No

Emergency contact details

Name

Relationship to You

Home Phone

Mobile Phone

Cultural Identity

Aboriginal or Torres Strait Islander

To assist with health initiatives- are you Aboriginal and/or Torres Strait Islander?

No
Yes - Aboriginal
Yes - Torres Strait Islander
Yes - Both

Country of Origin*

To tailor appropriate care, encourage understanding and appreciation between people from different nationalities and cultures, please identify your country of origin.

Do you require an interpreter service?

No
Yes

Please specify language

Your Health Information

Allergy Information*

No
Yes

Allergy Details

Medical History

Do you have or have you had a history of the following?

Other Details

Note – a list of all your current medication is required on first visit

Smoking*

No
Ceased
Yes

Smoking Ceased Date

How Many

Alcohol*

No
Yes

How Often

Recreational Drug Use

No
Yes

Type

Frequency

Family Health History Information

Do any members of your family have:

Family History Other

Privacy Statement and Consent

Consent*

Please read this consent text below carefully prior to confirming

This general practice collects your information for the primary purpose of providing proactive health care and to enable us to properly assess, diagnose and treat illnesses and medical conditions. In keeping with the Privacy Act 1988 and Australian Privacy Principles, the following information is provided on how your personal information may be used or disclosed and record your consent or restrictions to this consent.

Your personal information will only be used for the purposes for which it was collected or as otherwise permitted by law, and we respect your right to determine how your information is used or disclosed.

By signing below, you (as a patient/parent/guardian) are consenting to the collection of your personal information to be used for the following purposes:

• Administrative and billing purposes in the operation of our general practice.
• Reminder/recall notices for treatment and preventative healthcare issued by telephone, SMS or mail.
• Disclosure to others involved in your health care (e.g. specialists, diagnostic testing) within and outside this medical practice.
• Accreditation and quality assurance and to comply with other legislative requirements.
• For legal related disclosure as required by a court of law.
• For the purposes of research and training only where de-identified information is used.

At all times we are required to take all steps necessary to ensure your information remains confidential. Please complete the details below if you understand and agree to the following statements in relation to our use, collection, privacy and disclosure of your patient information.

I have read the information above and understand the reasons why my information must be collected, and the purposes for which my information may be used or disclosed. I understand that if my information is to be used for any other purpose other, my further consent will be obtained.

I give permission for my personal information to be collected, used and disclosed as described above. I understand only my relevant personal information will be provided to allow the above actions to be undertaken and I am free to withdraw, alter or restrict my consent at any time by notifying this practice in writing.

Name

This field is for validation purposes and should be left unchanged.

Moday – Friday	8:00am – 6:00pm
Saturday	8:30am – 11:30am
Sunday and Public Holiday	Closed