Classic form

New patient registration form with Medicare and IRN on it

A new patient form has to produce a file a doctor can safely open, which means a Medicare number with the right IRN, a medicines list that includes the things people forget, and consents that were actually read. This one asks nineteen questions and explains the two that people get wrong most often.

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The form itself

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Register as a new patient at Elm Street Medical

Please complete this before your first appointment. It takes about eight minutes and it means the consultation starts with the doctor rather than with the front desk.

About you

Your name, exactly as it appears on your Medicare card *

Title

First

Middle

Last

Date of birth *

How should your gender be recorded? *

Female

Male

Non binary

Different term, and I will tell the doctor

Prefer not to say

Home address *

Mobile *

Email for results and reminders *

Medicare and concessions

The IRN is the single digit printed to the left of your name on the Medicare card. On a family card every person has a different IRN, and a wrong one is the most common reason a bulk billed claim is rejected on the day.

Medicare number *

IRN, the number beside your name *

Medicare card valid to *

Concession or veterans card *

None

Pensioner Concession Card

Health Care Card

Commonwealth Seniors Health Card

DVA Gold Card

DVA White Card

Private health fund and membership number, if you have one

Your care

Preferred GP *

Your previous practice, if you had one

List everything you take, including the contraceptive pill, inhalers, anything bought over the counter, herbal preparations and vitamins. Interactions are the reason this question is asked, and the things people leave off are usually the ones that interact.

Medicines you take regularly *

Allergies and reactions *

Consents

My Health Record is the national record held by the government, not the practice file. Choosing no changes nothing about the care you receive here and it can be changed at any visit. The practice keeps its own record either way.

May the practice upload to and view your My Health Record? *

Yes, upload summaries and view my record

View only, do not upload anything

No, do not use My Health Record for me

I do not have one

Reminders and recalls by SMS

Appointment reminders the day before

Recalls when a result needs discussing

Preventive reminders such as vaccinations and screening

Two people, in the order you would like them called. The first is the person contacted in an emergency. Say the relationship plainly, because a first name alone is no use to an ambulance officer standing in a waiting room.

Emergency contacts *

#	Name	Relationship to you	Phone
1
2

By signing you confirm the details above are correct and that you have read how the practice collects, stores and shares health information. A copy of the privacy policy is on the practice website and at the front desk.

Signature, or a parent or guardian if the patient is under 16 *

Every field, and what it collects

The complete field list, in the order respondents meet it.

Your name, exactly as it appears on your Medicare cardNameRequired
Date of birthDateRequired
How should your gender be recorded?Single choiceRequired: Options: Female · Male · Non binary · Different term, and I will tell the doctor · Prefer not to say
Home addressShort textRequired
MobileShort textRequired
Email for results and remindersShort textRequired
Medicare numberShort textRequired
IRN, the number beside your nameShort textRequired
Medicare card valid toDateRequired
Concession or veterans cardSingle choiceRequired: Options: None · Pensioner Concession Card · Health Care Card · Commonwealth Seniors Health Card · DVA Gold Card · DVA White Card
Private health fund and membership number, if you have oneShort text
Preferred GPDropdownRequired: Options: Dr Amara Ellery, general practice and skin checks · Dr Tomas Keneally, chronic disease and diabetes · Dr Priya Raman, women and children · Dr Nathan Oduya, mental health and sports injuries · No preference, whoever is available soonest
Your previous practice, if you had oneShort text
Medicines you take regularlyLong textRequired
Allergies and reactionsLong textRequired
May the practice upload to and view your My Health Record?Single choiceRequired: Options: Yes, upload summaries and view my record · View only, do not upload anything · No, do not use My Health Record for me · I do not have one
Reminders and recalls by SMSMultiple choice: Options: Appointment reminders the day before · Recalls when a result needs discussing · Preventive reminders such as vaccinations and screening
Emergency contactsTableRequired: Columns: Name · Relationship to you · Phone
Signature, or a parent or guardian if the patient is under 16SignatureRequired

The two questions patients get wrong, and what the form does about them

The first is the IRN. On a family Medicare card every person has a different single digit printed beside their name, and the wrong one rejects a bulk billed claim at the counter. So the IRN is its own field with a one digit pattern and a paragraph above it saying where to look. The second is medicines. People list prescriptions and leave off the pill, the inhaler, the fish oil and whatever they bought at the pharmacy, which are exactly the ones that interact. The paragraph above that box names all four.

The Australian pieces on this form

Medicare, the IRN and the card expiry are the identifiers a practice needs to claim, and the card still has to be sighted once, which the thank you screen says rather than pretending the form completes the job. The concession radio lists the real cards, including both DVA colours, because they change what a patient pays. My Health Record is asked as a four way choice rather than a tick, since view only is a real preference and a patient who does not have one should not have to guess. The privacy paragraph points at the practice policy, which is what the Australian Privacy Principles expect a health service to make available.

How to adapt this form

A physiotherapy or allied health clinic drops the Medicare block to a provider referral question and adds a body chart upload, because the funding path is a referral or a private claim rather than a bulk billed item. A paediatric practice puts the guardian details first, adds a school field and an immunisation history question, and makes the signature explicitly the guardian. A telehealth service keeps every field and adds the patient current location, since the prescriber needs the state the patient is physically in at the time of the consultation.

What makes this form work

The IRN gets its own one digit field

A pattern that accepts a single digit, and a paragraph saying it is printed beside the name and differs for every person on a family card. That is the mistake that rejects a claim at the counter.

The medicines question names what people forget

The contraceptive pill, inhalers, over the counter purchases, herbal preparations and vitamins are all listed above the box, because those are the ones that interact and the ones nobody thinks to write down.

My Health Record is a four way choice, not a tick

Upload and view, view only, no, and I do not have one. View only is a real preference, and the paragraph says choosing no changes nothing about the care given at the practice.

Questions people ask

Why is the IRN a separate field with a pattern?

Because it is a single digit and it is the part people misread. The pattern accepts one digit from 1 to 9 and nothing else, which stops somebody typing the whole card number twice. The paragraph above explains that it is printed to the left of the name and that every person on a family card has a different one, which is the fact most patients have never noticed.

Can this form claim a Medicare rebate?

No. The form creates a patient record and nothing more, and the thank you screen says the card still has to be sighted at the first visit. Claiming happens in the practice software, where a rejected claim can be corrected and resubmitted. A form that pretended otherwise would send patients home believing something had been lodged.

Is a signature needed on a patient registration form?

It is here, because the paragraph above it confirms the details are correct and that the privacy policy has been read. The signature is drawn or typed by the patient and printed into the response PDF, so the mark and the statement it covers stay together. The label allows for a parent or guardian where the patient is under 16.

Why ask for allergies as free text rather than a tick list?

Because the useful part is the reaction, not the substance. A tick beside penicillin tells a doctor nothing about whether the patient had a rash at six or an anaphylaxis at thirty. The placeholder asks for what you react to and what the reaction is, and it asks for none known rather than an empty box, so silence never has to be interpreted.

How should SMS reminder consent be collected?

As separate ticks, not one. Appointment reminders, recalls when a result needs discussing, and preventive reminders such as vaccinations are three different intrusions, and a patient who wants the first rarely wants the third. Splitting them also means a refusal of one does not read as a refusal of all three when somebody looks at the record later.

Does the form store health information safely enough?

The responses sit in the practice account behind a login, and the form itself can be locked down further with access control, including requiring a sign in before it can be opened. What the page will not claim is any accreditation. A practice handling health records should read the responses into its clinical system and set a retention rule there.

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Sources

Written and checked by the OneCraft team. Last checked 12 September 2026.