Sydney Premier Medical & Health Centre

Shop 2, Ground Floor, 309 Pitt St

Sydney, NSW 2000

Phone : (02) 8964 8677

Email : bookings@spmh.com.au

ONLINE PATIENTS REGISTRATION

1 PATIENT DETAILS

Title :

First Name :

Last Name/Family Name/Surname :

Middle Name :

Date of Birth : (DAY / MONTH / YEAR)

Gender :

Street Address : (Australia Address)

Suburb : (e.g. Sydney)

State :

Postcode : (e.g. 2000)

Email Address :

Ethnicity / Nationality :

Mobile : (e.g. 0423507898)

Home Phone : (e.g. 89648677)

Work Phone : (e.g. 89648677)

Occupation :

2 EMERGENCY CONTACT

Title :

First Name :

Last Name/Family Name :

Relationship :

Contact No. : (e.g. 0423507898)

Alt. Contact No. : (e.g. 89648677)

3 HEALTH FUND

Medicare Australia

A Medicare No. :

B Reference No. :

C Valid To : (MONTH / YEAR)

Do you have a Veteran Affairs (DVA) ? If yes, please provide the following information.

File Number :

Type :

Do you have any other Australian Government / Concession Card ? (Student Concession excluded) If yes, please provide the following information.

Type :

Membership Number :

Valid To : (DAY / MONTH / YEAR)

Do you have any OSHC Insurance? If yes, please provide the following information.

Insurance Name :

Membership Number :

Expire Date : (DAY / MONTH / YEAR)

4 MEDICAL INFORMATION

Tobacco How many cigarettes per day ?

Alcohol How many glasses per week ?

Allergies Please list down any allergies. (Substance - Reaction e.g. Penicillin - Rash)

Medical History Please list down any Medical history including current. (Year - Condition/Operation e.g. 1999 - Asthma)

Family History Please list down any family history of Cancers, Diabetes, Heart Diseases, etc. (Relation - Condition e.g. Mother - Diabetes)

Current Medication Please list down any ongoing medication. (Medication - Dose @ Frequency e.g. Yasmin - 1 @ daily)

5 SUBMISSION

DECLARATION

I hereby confirm that the information provided by me herein is true and correct.