Patient Details

First Name

Last Name


Date of Birth

Address

Street Number and Name *

Suburb *

State *

Postcode

Medicare

Medicare Card Number

Expiry Date *


Position on Card *

Patient's Previous Practice Details

Name of Previous Practice *

Practice Phone Number *

Practice Fax Number

Consent to Transfer Medical Records

All existing recordsAllergies & adverse reactionsCurrent medicines listMedical history (current and past active and inactive) as recordedFamily history as recordedSocial history as recordedHealth risk factorsImmunisations as recorded
I authorise for this release to be
[checkbox* checkbox-664 use_label_element "Shared via secure electronic transfer through [E-transfer platform] to [Clinic details] in a XML file"]
I give consent for my medical records to be released to this practice *