Forms Print New Patient Form New Patient Registration Form Title MrMrsMissMsOther (please specify)…………………………………. Gender (please circle) MaleFemaleOther Contact DetailS By providing us with the phone numbers below, you agree to the practice staff to leave messages identifying the practice as the caller I consent to receive SMS for reminders, recalls, results and other SMS messages YESNO Other Information YESNO To assist with health initiatives, are you Aboriginal or Torres Strait Islander? NoAboriginalTorres Strait IslanderAboriginal & Torres Strait Islander Do you have any of the following cards? MedicareHealth Care CardPension CardVeterans Affairs Please note: you must present the above cards to reception, they must be in date and valid to receive any rebates or concessions including bulk bill services. MaleFemaleOther MaleFemaleOther Please provide the reception staff a copy of your legal power of attorney documents. By signing this form, I understand and acknowledge Fees charged by Port Pirie Medical Centre (PPMC) are only related to services provided by the practice. I consent to PPMC checking Medicare Item Eligibility online through Services SA (HPOS) I will be personally responsible for the payment of non-attendance fees should I fail to attend an appointment or to give reasonable hours’ notice when cancelling an appointment. I understand that whilst PPMC makes every effort to send SMS appointment reminders, non-receipt of an SMS reminder is not a valid reason for non-attendance scheduled appointment I am responsible for notifying PPMC when there is a change in my contact details PATIENT HEALTH DETAILS All information will be kept confidential Your Medical History – Do you have or have you had history of? Past operations/surgeries AsthmaDiabetesHeart DiseaseStrokeHigh BloodPressurePace MakerCancer TypeMental HealthOtherPlease specify Current Medications (including over the counter medications, vitamins & minerals) Allergies Do you have any allergies or are you sensitive to any medications or dressings? If so, what reaction have you experienced? Advanced Care Directive Do you have an Advanced Care Directive for end of life care? Please circle YesNo Please provide a copy to reception staff for your file. If you wish to Know more about ACD’s, please ask your GP or speak to a Nurse. Immunisations Did you receive the scheduled/recommended vaccinations as a child and in high school? Please circle YesNo When was the last time you received a vaccination for the following Vaccination Date Unsure / Never UnsureNever UnsureNever UnsureNever UnsureNever UnsureNever
