Patient Patient Registration Form PATIENT DETAILS Title Mr Mrs Miss Ms Dr Prof Gender Male Female Other First Name Last Name Preferred Name Date of Birth English is a Second Language? Yes No Aboriginal Torres Strait Islander PATIENT CONTACT DETAILS Home Phone Mobile Phone Work Phone Email Address City / Suburb Postcode State NEXT OF KIN CONTACT DETAILS Name Next of kin - Relationship Spouse/Partner Parent Child Friend Other Home Phone Work Phone Mobile Phone Email EMERGENCY CONTACT DETAILS Is the emergency contact same as your next of kin? If yes, you do not need to fill this section Yes No GENERAL PRACTITIONER General Practitioner’s Name Practice name or Address EMERGENCY CONTACT DETAILS Medicare Card No. Expiry Medicare Address (if different to your residential address) PRIVATE HEALTH INSURANCE Do you have private Medical insurance Yes No Details PENSION / HCC/DVA Card Do you have an aged pension card, healthcare card or a DVA card Yes No Details MEDICAL HISTORY Have you ever been diagnosed with high blood pressure? Yes No Have you ever been diagnosed with high cholesterol? Yes No Have you ever been diagnosed with diabetes? Yes No Have you ever been diagnosed with kidney problems? Yes No Have you smoked? I smoke now Never In the past Do you have a family history of heart attacks, bypass surgery or coronary stents? Yes No Have you previously had heart attacks, stents, bypass surgery? Yes No Have you previously been diagnosed with any heart condition? Yes No Do you have a previous history of heart attacks, stands, bypass surgery? Yes No Do you have any other known heart condition? Yes No Do you have any allergies? Yes No Do you have any other medical conditions? Do you have any symptoms or specific concerns regarding your health? Please list all current medications (including dose and times taken) Please upload any documentation if available COLLECTION OF PERSONAL INFORMATION The Privacy Act of 1988 requires all health practitioners to obtain consent from their patients to collect, use and disclose patients' information. Please read our privacy policy carefully and if you consent check the box below. I have read the privacy policy (click here) and consent to the handling of my information by eCardiology for the purposes set out in this policy, subject to any limitations on access or disclosure that I notify this practice of. * CONSENT AND SIGNATURE I understand the process of Telehealth consultations and agree to receive services via Telehealth if clinically necessary. In the case of a Telehealth appointment I agree to the assignment of the Medicare benefit directly to the provider. * I confirm that above information I have provided is true, complete and accurate. * Submit
