Patient Update Form

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

Thankyou for updating your details. If you have never been seen here before please use the New Patient Information form.

Title *

First Name *

Last Name *

Date of Birth *

Gender *

PRONOUN *

Birth Sex *

Preferred Contact Number *

Alternate Contact Number

Email Address

Has your home address changed? *

YesNo

Has your Postal Address Changed? *

YesNoSame as residential address and not changed

Home address *

City *

State *

Postcode *

Have your Medicare card details changed? *

YesNo

Medicare Card Number *

Medicare Reference Number *

Medicare Expiry *

Do you have a Pension or Concession Card *

YesNo

Do you have a DVA Card?

YesNo

Have your pension card details changed?

YesNoNot sure

Have your DVA details changed?

YesNoNot sure

Would you like to change your Emergency contacts?

YesNo

In case of EmergencyNext of Kin

Phone number

Relationship

Emergency Contact Name

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

Access to information

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

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

NoYes- My Next of Kin Yes- My emergency contactYes- Someone else

If you ticked "yes" please provide the following

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 Kin Yes- My emergency contactYes- Someone else

If you ticked " yes" please provide the following

Fees and Charges

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.

I understand the billing policy and agree to pay for my consultation and any tests or items provided on the day. *

Update your Health History

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Please upload any documents that apply.