Patient Registration

For Patients

When you arrive at Twin Green Healthcare, our friendly reception staff will warmly welcome you into our reception area. If you haven’t already completed a New Patient Form before your visit, they will be happy to assist you in filling it out. We’re here to ensure your experience is smooth and comfortable from the moment you step in.

Filling this out in advance will help streamline your visit, but it’s a quick and straightforward form. It allows Twin Green Healthcare to identify you and gain an initial understanding of your primary health concerns, ensuring we provide the best possible care from the start.

New Patient Form

Patient Registration and Information Form

At Twin Green Healthcare, we are dedicated to delivering the highest quality care. To ensure this, we ask that all information provided is complete, accurate, and up to date. Completing this form is required for all patients, and if you need any assistance, our friendly team is always here to help.

Title (Required)

First Name (Required)

Last Name (Required)

Preferred Name

Date of Birth (Required)

Occupation (Required)

Gender (Required)

Phone (Required)

Email (Required)

Address (Required)

Street Address

City

State

Post Code

Next of Kin (Required)

Next of Kin - Name

Relationship

Phone Number

Emergency Contact (Required)

Emergency Contact - Name

Relationship

Phone Number

Do you Identify as: (Required)

Aboriginal Torres Strait Islander Both Neither

Medicare Number

Expiry Date

Pension / Health Care Card

Expiry Date

Dept. of Veterans' Affairs

Expiry Date

Reference

Current Medications

Past Medical History

Past Operations

Social and Lifestyle History

Alcohol

Non Drinker Drinker

Smoking

Currently smoking Ex-smoker Non-Smoker Vaping / E-cigarettes

How often do you exercise vigorously?

Never Monthly Fortnightly Weekly Daily

Based on the above question, how long would you exercise for?

10-15min 15-30min 30-60min +60min

Height, Weight, Waist, Family History

Height

Weight (kg)

Waist (cm)

Family History

Diabetes Asthma Heart Disease Cancer Other

Covid Vaccinated

Up-to-date Pending Unvaccinated Interested in discussion regarding booster vaccination

Cancer Screening

Please check the box if you have had any of the following:

Bowel Screening Cervical Screening Breast Screening

Any Other Information

Health Information Collection and Use Consent Form

It is important that you provide us with your personal details and detailed medical history so we can appropriately assess, diagnose, treat and proactively manage your health care needs. We aim to protect the privacy and security of your health and personal information. You can request a copy of our privacy policy which includes information on the collection, use, and disclosure of the information provided. This information may be used to facilitate:

Patient administration by staff, nurses, and doctors of Twin Green Healthcare
Billing purposes including your health insurance company, if required.
Compliance with Medicare and government, legislative or regulatory authorities.
Disclosure to other medical professionals including but not limited to doctors, specialists, and other allied health practitioners within, and external to, our practice.
Research and quality improvement activities associated with improving patient experience, community health or practice management. This information typically does not identify the patient and is used anonymously.
For patient communication, reminder letters, referral letters, and appointment reminders.

Patient Authority (Required)

I have provided a full and detailed medical history that is up-to-date and accurate as far as practical

I have read the information above and consent to the collection and use of the information provided

I am aware of my rights to access the information collected about me except in some circumstances where this information may be legitimately held (with a supporting explanation)

I consent to the handling of my information by the practice for the purposes listed above

Patient Name (Required)

Patient Last Name (Required)

Date (Required)

Signature (Required)

Name and Signature as Guardian for a Child

Guardian Name (First)

Guardian Name (Last)

Guardian Signature