Patient Registration Form

Patient Registration Form

PATIENT DETAILS

Given Name/s

Middle Name/s

Surname

Preferred Name

Date of Birth *

Pronouns

Mobile Phone

Home Phone

Occupation

Email

Street address

Suburb

Postcode

Do you identify as:

AboriginalTorres Strait IslanderBoth Torres Strait Islander & AboriginalPrefer not to say

MEDICARE

Do you use a different name on your medicare card?

YesNo

Medicare First Name

Medicare Surname

Medicare Card No.

Reference no.

Expiry

PRIVATE HEALTH INSURANCE

Do you have private health insurance?

YesNo

Health Fund Provider

Membership No.

DVA Card

Do you have a DVA card?

YesNo

DVA Card Type

GoldWhiteOrange

DVA No.

EMERGENCY CONTACT DETAILS + NEXT OF KIN

Emergency contact name

Emergency contact number

Other - please specify:

Is your next of kin the same as your emergency contact?

YesNo

Next of kin name

Next of kin contact number

Other Next of Kin - please specify:

GENERAL PRACTITIONER

Your regular GPs Name

GP's practice name

MEDICAL HISTORY

Other (please speficy)

Recently, do you have problems with body weight? *

LossGainNo

Recently, do you have problems with poor sleep? *

YesNo

Recently, do you have problems with mood and/or anxiety? *

YesNo

Other (please specify)

Do you currently smoke cigarettes? *

YesNo

Were you previously a cigarette smoker? *

YesNo

Please list all previous surgical procedures (Procedure name, Year, Doctor, and Hospital):

Please list your current medications (Name, Dose, and Frequency):

List any medication allergies:

What is your height (cm)? *

What is your weight (kg)? *

Have you had recent blood tests? *

YesNo

At which pathology provider were they collected? (I.e. QML, Sullivan Nicolaides, other)

Have you had recent imaging tests/ scans? *

YesNo

At what imaging provider were they performed? (I.e. I-Med, Qld Xray, Q-Scan, Lumus, Other)

PRIVACY CONSENT

Please confirm that you have read our Privacy Statement available at drmorton.com.au/privacystatement *

Yes

Do you consent to the Queensland Centre for Gynaecological Cancer (QCGC) storing your patient data for the purpose of research, education and to be reviewed in quality assurance programs to further improve patient outcomes? *

YesNo

Do you consent to being contacted by or receiving information from QCGC Research regarding clinical trials that may be available to you? *

YesNo

Do you consent for your records to be uploaded to My Health Record? *

YesNo

Do you consent to data from your medical history and results being presented at a multi-disciplinary meeting as part of best practice in cancer care and quality assurance? *

YesNo

Do you consent to receive healthcare correspondence by email? *

YesNo

For example normal test result notifications, surgical cost estimates, pathology/radiology request forms etc.

Dr Morton utilises a note taking transcription tool called Heidi to accurately and efficiently capture the details of discussions and the outcomes of your appointments. Heidi ensures tha the doctor can focus more on conversation and less on manual note taking, enhancing the quality of care you receive. Do you consent for Dr Morton to use Heidi during your consultation? *

YesNo

SIGNATURE

I confirm that the above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

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