Intake, classic form

New patient registration template

A new patient registration with Medicare and concession details, preferred clinician, medicines and allergies, record consent, reminders and emergency contacts.

19 questions, 16 required, as a classic form

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The New patient registration template as a respondent sees it, top of the form

Every question

  1. Your name, exactly as it appears on your Medicare card (required)

    Full name

  2. Date of birth (required)

    Date

  3. How should your gender be recorded? (required)

    Single choice: Female, Male, Non binary, Different term, and I will tell the doctor, Prefer not to say

  4. Home address (required)

    Short answer

  5. Mobile (required)

    Short answer

  6. Email for results and reminders (required)

    Short answer

  7. Medicare number (required)

    Short answer

  8. IRN, the number beside your name (required)

    Short answer

  9. Medicare card valid to (required)

    Date

  10. Concession or veterans card (required)

    Single choice: None, Pensioner Concession Card, Health Care Card, Commonwealth Seniors Health Card, DVA Gold Card, DVA White Card

  11. Private health fund and membership number, if you have one

    Short answer

  12. Preferred GP (required)

    Dropdown: [Doctor 1], general practice and skin checks, [Doctor 2], chronic disease and diabetes, [Doctor 3], women and children, [Doctor 4], mental health and sports injuries, No preference, whoever is available soonest

  13. Your previous practice, if you had one

    Short answer

  14. Medicines you take regularly (required)

    Long answer

  15. Allergies and reactions (required)

    Long answer

  16. May the practice upload to and view your My Health Record? (required)

    Single choice: 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

  17. Reminders and recalls by SMS

    Multiple choice: Appointment reminders the day before, Recalls when a result needs discussing, Preventive reminders such as vaccinations and screening

  18. Emergency contacts (required)

    Table

  19. Signature, or a parent or guardian if the patient is under 16 (required)

    Signature

What you fill in

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