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New Patient Information Form

Medicare Number*

DVA Gold / White

Concession Card eg:Pension/HCC/Seniors HCC*

Address

Details of your next of kin

Details of your Emergency Contact

Do You Require an Interpreter Service

Do You Identify as Being

Aboriginal origin

Torres Strait Islander origin

Other Cultural group(please state)

Reminder Systems:

Our practice provides our patients with preventive care and early case detection reminderse.g. immunisations annual health checks, skin checks and pap smears.

Do you wish to have any relevant health reminders sent to you?

Do you consent to SMS contact reminders from the surgery?

Patients Signature or Parent / Guardian ( if child is a minor)

Date