New Patient application and information form

We are committed to providing our patients with the best quality care.

Please complete the following details and submit your application to reception.

Our books are conditionally open according to strict criteria - we are not able to accept all new patient requests.

Title

First Name *

Last Name *

Date of Birth *

Gender

Pronoun

What is your birth sex? *

Preferred Contact Number *

Alternate Contact

Home address *

City *

State *

Postcode *

Knowing your cultural background can help us provide healthcare that meets our individual needs.

What is your country of birth? *

What is your cultural background/ethnicity?

Are you of Aboriginal or Torres strait Islander backgound? *

NoYes AboriginalYes Torres Strait IslanderYes both

Is English your first language? *

YesNo

If no please specify

Do you require an interpreter - what language?

Medicare Card Number *

Reference Number *

Medicare Expiry *

Do you have a concession or pension card? *

YesNo

Do you have a Department of Veterans Affairs card? *

YesNo

Alternative contact people *Next of Kin

Phone number *

Relationship

Optional- other than the Next of Kin

Access to Information

In accordance with privacy legislation we are unable to release any information either verbally or written without your consent.

Do you authorise a nominated person to access HEALTH INFORMATION on your behalf?

NoYes- My next of KinYes- My emergency contactYes- Someone else

Do you authorise a nominated person to be able TO COLLECT scripts/pathology forms/referrals and other paperwork on your behalf? *

NoYes- My next of KinYes- My emergency contactYes- Someone else

Our practice undertakes research, professional development, and quality assurance and improvement activities to improve patient care. Confidentiality and privacy will be maintained. Do you consent to your health record being reviewed as part of the quality improvement activities at our practice? *

YesNo

Do you have an Advanced care directive for end of life care? For more information please talk to your GP. *

YesNo

I confirm that the information I have given (on this form) is correct. I consent to sharing of all relevant information between the general practitioners, specialists, nurse practitioners, nurses, allied health providers and non-clinical staff for the purpose of managing my health. I understand this information will be used to fulfil their duties in the course of planning and managing my health care. *

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Dubbo Family Doctors is a private billing practice, this enables us to provide high quality care, service and facilities. Fees apply for services and are payable on the day of your appointment.

A full list of fees and charges are available on our website or from reception.

If you are unable to attend an appointment it is essential that you contact the surgery to cancel and/or re-schedule your appointment at least 24hrs prior. A non-attendance fee of $55 is payble for missed appointments.

To ensure our team have time to understand your needs and medical history we require all New Patients to have a double appointment. A $100 New Patient bond is payable at the time you make your first appointment. After the appointment this will be credited toward the cost of your consult.

If you fail to attend the appointment this amount is non-refundable

I understand this bond will not be refunded if I fail to attend my appointment. *

Signature *

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New Patient Information

We will request a copy of your medical records from your usual doctor, however please provide the following summary of your health history.

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

Operations *

YesNo

Arthritis *

YesNo

Heart attack /Angina *

YesNo

High Blood Pressure *

YesNo

Asthma *

YesNo

Osteoporosis *

YesNo

Strokes or Mini Strokes *

YesNo

Diabetes *

YesNo

Skin Cancers *

YesNo

Emphysema, chronic bronchitis or COPD *

YesNo

Depression or anxiety *

YesNo

Other mental illness *

YesNo

Do you have any allergies? *

YesNo

What medicines are you currently taking?

Please include all medications including over the counter medications, vitamins, minerals, contraceptives.

Name of Medication

Dose and Frequency

When did you last have?

An overall check up? *

Cervical Screen

Mammogram

Prostate Check

Have you ever performed a bowel cancer screen? (Stool Test, faecal occult test, colonoscopy)

Have you had the following immunisations?

Tetanus Booster *

YesDon't KnowHaven't had one

Whooping Cough (Pertussis) *

YesDon't KnowHaven't had one

Hepatitis A *

YesDon't KnowHaven't had one

Hepatitis B *

YesDon't KnowHaven't had one

Influenza *

YesDon't KnowHaven't had one

Pneumoccal *

YesDon't KnowHaven't had one

HPV (Gardasil/Cervarix) *

YesDon't KnowHaven't had one

Zostavax (Shingles) *

YesDon't KnowHaven't had one

COVID *

YesDon't KnowHaven't had one

Japanese Encephalitis *

YesNoNot sure

Children- If completing this form for a child, are their immunisations up to date?

YesNoNot sure

Do any members of your family have a history of any of the following conditions?

Heart Disease? *

YesNo

Cancer? *

YesNo

Asthma? *

YesNo

Diabetes? *

YesNo

Mental Illness? *

YesNo

Other health condition? *

YesNo

What is your occupation?

Do you drink alcohol? *

Do you smoke? *

YesNoUsed to smoke- Now ceased

When did you cease smoking?

What do you smoke?

CigarettesVapesBoth

Do you use any other drugs?

YesNoStopped using

Workcover/Insurance claims

Do you have any current insurance or Workcover claims in progress? If yes please give details. *Our practice will not take on the management of pre-existing workcover matters, provide certificates or complete reports for pre-existing workcover claims.

When was your last full skin check?

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New Patient application and information form

Access to Information

Fees and Charges

New Patient Information

Your Health History

Current Medications

Immunisations

Family History

Social History

Workcover/Insurance claims

Sun Protection