New Patient Registration NEW PATIENT REGISTRATION Welcome to Upwey Doctors. To enable us to care for you,please complete the form below with the necessary information and return it to the reception/submit it online. If the patient is a child aged 15 or under, this form must be completed by a Parent/Guardian. If any section of this form is not applicable, then please leave it blank. The clinic complies with all national privacy regulations and as such, all information collected,used and stored for any clinical audit remains anonymous as required under the National Privacy Act 1988. Patient Name: Date of Birth: If Patient is a Child, Name of Parents/Guardian: Address: Suburb: State: Postcode: Home Phone: Work Phone: Mobile: Email: Next of kin: Relationship: Phone: Medicare No.: Position: Expiry date: Health C/Card Veteran Affairs Pensioner Card Other Card Number: Expiry Date: Private Insurance: Yes No Fund Name: Membership No.: Are you of Torres Strait or Aboriginal Origin? Yes No Would you like to have copies your past medical history transferred from another clinic? [By doing so, you will still be able to attend your previous surgery but this will enable your doctor to know a bit more about you and your medical conditions] Yes No Declaration: I agree that all the information I have provided is true and correct to the best of my knowledge.