PRIVATE HEALTH INSURANCE (IF APPLICABLE - IF NONE, SKIP)

PRIVATE HEALTH FUND

LEVEL OF COVER (GOLD/SILVER/BRONZE/EXTRAS)

DATE COMMENCED (IF KNOWN)

GENERAL PRACTITIONER

NAME

PRACTICE

NEXT OF KIN DETAILS

NEXT OF KIN NAME

RELATIONSHIP TO YOU

NEXT OF KIN ADDRESS

NEXT OF KIN PHONE NUMBER

YOUR MEDICAL HISTORY

Current Weight

Height

BMI (if known or leave blank)

Are you a smoker?

YesNoEx-Smoker (give details)

How many per day? (or when did you quit)

Do you drink alcohol?

YesNo

How much per week?

CURRENT MEDICAL ISSUES? (List all)

INFORMATION CONSENT

CONSENT : I give my consent for doctors and staff to collect, use and disclose my personal information. The purpose for collecting this information is to provide quality medical and health related services, billing and account keeping as required for practice management. I am responsible for all my accounts. I agree that my information will be managed in accordance with the National Privacy Act (1988).

SIGNATURE

Draw signature|Type signatureClear