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New Patient Registration Form

Please fill in the online form below with your details.

If you prefer to download a PDF version of the form, download the form here.

    Preferred Title:

    Name:(as on Medicare card)

    Date of Birth

    Sex at Birth:

    Gender Identity


    :

    Nationality

    Do you identify as:

    Street Address

    Postal Address

    Same as above

    Contact Details

    Medicare Details

    Health Care Card Details

    DVA Gold/White

    Pension Card Details

    Next of Kin

    Emergency Contact

    same as Next Of Kin

    Personal Details

    (If Yes, please list)







    (e.g. Adopted)

    Cairns Health Collective participates in Quality Improvement involving the sending of de-identification information for Health Data. Please inform reception if you do not wish to participate.

    Privacy

    Your medical record is a confidential document. It is always the policy of this practice to maintain the security of personal health information and to ensure that this information is only available to authorised members of staff.

    Please refer to our Privacy Policy located at Reception or via our website.

    Consents

    Do you consent to the Doctors at Cairns Health Collective uploading and accessing your My Health Record?

    Yes

    No

    Do you wish to receive SMS notifications from Cairns Health Collective for the following?

    Yes

    No

    Yes

    No

    Yes

    No

    Yes

    No

    Do you consent to the Staff at Cairns Health Collective sending Emails to you and other health care providers which may contain private/clinical information and are not encrypted?

    Yes

    No

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