Please enable JavaScript in your browser to complete this form.Basic DetailsFamily Name *Given Name *Preferred NameTitle *MrsMrMsMasterMissDrOtherDate of Birth *GenderFemaleMaleOtherContact InformationHow can we get in contact with you?Address *Home PhoneMobile Phone *Work PhoneEmail *Next of KinBest person for us to contact on your behalf in the case of an emergency.Name *FirstLastRelationship *Phone *Emergency ContactMust be different to Next of Kin.Name *FirstLastRelationship *Phone *Personal InformationMore about you.Marital Status *Occupation *SexualityHeterosexualHomosexualBisexualOtherDo you have an advance directive for end of life care?YesNoBenefits and ConcessionsMedicare Number *Medicare Expiry *Medicare Reference Number *The number next to your name on the Medicare card.Pension/Health Care Card NumberPension/Health Care Card ExpiryDept. of Veterans' Affairs Card NumberDept. of Veterans' Affairs Card ExpiryCultural BackgroundKnowing your cultural background can help us provide healthcare that meets your individual needs.Do you identify yourself as: *AboriginalTorres Strait IslanderBothNone of the aboveOther Cultural Background *e.g. Mediterranean, Asian, AfricanCountry of Birth *Is English your first language? *YesNoDo you need an interpreter? *YesNoPlease specify languageMedication and AllergiesCurrent Medications (not prescribed by HHD; including over the counter medications, vitamins, and minerals):Do you have any allergies and/or are you sensitive to any drugs or dressingsYesNoIf yes, please list and describe reactionsConsentOur practice uses a reminder system to help maintain your health. The practice sends reminders by post, email, telephone or SMS for procedures such as vaccinations, Pap Smears and other health reviews.I consent to be contacted with a reminder to help maintain my health *YesNoOur practice also sends information to the Australian Childhood Immunisation Register & Pap Smear Register. These registers also send reminders, which can be helpful if you move.I consent to be contacted with a reminder to help maintain my health *YesNoThe practice routinely sends SMS appointment reminders to patients.I consent to be contacted with an SMS Appointment Reminder *YesNoThe practice routinely needs to validate your Medicare details with Medicare I consent to Heroes Home Doctor contacting Medicare to confirm my Medicare details *YesTransfer of Health InformationYou may have consistently consulted with a GP at another practice. The health information held by that GP may assist with your future health care needs. You may wish to have a copy or summary of your health care records transferred to this practice. Please ask a receptionist or GP about how this can take place.By pressing the below submit button, you are electronically signing this document. Please ensure your details are correct before pressing submit. Thank you for your cooperation.NameSubmit
