New Patient Registration Form Step 1 of 6 - Personal Details 16% Personal DetailsTitle*Please SelectMrMsMissMrsDrProfSurname* Given Names* Birth Sex*Please SelectMaleFemaleOtherUnknownGender IdentityPlease Select;FemaleMaleNon-binaryGender diverseTransgenderDifferent identityPronounsPlease Select;She/ Her / HersHe / Him / HisThey / Them / ThiersDate of Birth* DD slash MM slash YYYY Marital Status*Please SelectSingleMarriedDefactoSeparatedDivorcedWidowedHome Address* Street Address Suburb State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country I have a different Postal Address Postal Address Street Address Suburb State / Province / Region Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone Number Work Number Mobile Number Email SMS Consent Select All Appointments Clinical Communication Clinical Reminders Health Awareness Please TickPreferred Contact Method Home Phone Work Phone Mobile Phone Email SMS Please TickOccupation Past Occupation Health Care DetailsDo you have a Medicare Card?Please Select;YesNoMedicare Card Number* Medicare Reference Number* Card Expiry Month*Please Select;010203040506070809101112Card Expiry Year*Veterans Affairs Card No Type of Veterans CardPlease Select;GoldWhiteCard Expiry DD slash MM slash YYYY Pension, or Health Care Card Card Expiry DD slash MM slash YYYY Emergency Contact DetailsNext of Kin (Full Name) Contact Number Relationship to you Emergency Contact (Full Name) Contact Number Relationship to you Do you have an advance health directive for end of life care?*Please SelectYesNoNot Sure EthnicityAustralia is a genuinely multicultural society. To tailor appropriate care, encourage understanding and appreciation between people from different nationalities and backgrounds please complete the following section.Ethnicity (Place of Birth Parents)Please Select;Australian, Non IndigenousAboriginal, but not Torres Strait IslanderTorres Strait Islander, but not AboriginalBoth Aboriginal & Torres Strait IslanderOtherOther Cultural Background Country of Birth Is English your first language?Please SelectYesNoDo you require an Interpreter?Please SelectYesNoPlease specify language Medical InformationDo you have any Allergies to Medications?*Please SelectYesNoPlease SpecifyAre you taking any Medications?*Please SelectYesNoPlease SpecifyDo you have a history of any of the following conditions? Operations (give details) Asthma Diabetes Hypertension Chronic Illness (give details) Other (give details) High Blood Pressure DetailsIs there a family history of any of the following conditions? Diabetes Heart Disease Asthma Mental Illness (give details) Cancer (give details) Other (give details) High Blood Pressure DetailsDo you smoke?*Please SelectYesNo - I have quitNeverHow many a day? Which year did you quit? Smoking HistoryPlease SelectLightModerateHeavyDo you exercise regularly?*Please SelectYesNoHow much alcohol do you consume?*Please SelectEveryday3 times a weekOnce a monthOtherOther Alcohol Consumption Do you have any other relevant medical conditions?Have you had a Cervical Screening?Please Select;YesNot SureNeverDate of last Pap Smear DD slash MM slash YYYY Have you had a Breast Check?Please Select;YesNot SureNeverDate of last Breast Check DD slash MM slash YYYY Have you been immunised against Influenza?Please Select;YesNot SureNeverDate of Influenza Vaccination DD slash MM slash YYYY Have you been immunised against Pneumococcal?Please Select;YesNot SureNeverDate of Pneumococcal Vaccination DD slash MM slash YYYY ConsentAt the Bridge Family Practice we strive to provide high quality care, appropriate to meet our client's health requirements. By becoming a patient of The Bridge Family Practice and signing this new patient form I agree and consent to the following;Consent* I agree I consent to the use of my personal health information by The Bridge Family Practice and other health care providers involved in my medical treatment. I consent to the disclosure of my personal health information by the above names practice to other health care providers involved directly or indirectly in my personal health care of medical treatment. As part of the preventative health services offered by this practice we send out follow up reminders and recalls when routine investigations are due. I consent to receive follow up reminders and recalls to be sent through my preferred method of contact. Please telephone the surgery to cancel at least 4 hours prior to your appointment. Failing to do so will result in a fee of $40.00 per 10 minute booking time. Payment of such fee will be required in full prior to any future booking.Patient Signature*Name Date DD slash MM slash YYYY Upload your PhotoMax. file size: 25 MB.How did you hear about us?*Please Select;GoogleHealth EngineFamilyFriendOtherPlease Specify