Patient Information Form

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Medicare Number & Ref

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Pension Number

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Health Care Card Number

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Health Care Card Number

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Private Health Cover

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Next of Kin Details

Reminder Systems: Our practice provides our patients with preventive care and early case detection reminders e.g. immunisations, annual health checks, skin checks and pap smears.

Do you wish to have any relevant health reminders sent to you?
If we need to contact you what is your preferred method of contact:

Patient Background: Australia is a genuinely multicultural society. To tailor appropriate care, encourage understanding and appreciation between people from different nationalities and backgrounds.

Do you identify as someone from a culturally and/or linguistic diverse background?
To assist with health initiatives – are you an Aboriginal or Torres Strait Islander?

Your health History

Do you have or have you had a history of the following?
Do you have any allergies or are you sensitive to drugs or dressings?
Tetanus Booster
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Hepatitis B
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Hepatitis A
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Influenza
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Pneumococcal
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Polio
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If completing this form for a child are their immunisations up to date?

Immunisations

Have you had the following immunisations? (list date where appropriate)

Family History

Have any members of your family had:

Social History

Do you use any of the following: (list amount where appropriate)

Tobacco
Alcohol
Drug Use
Measurements

Contact Us

Opening Hours

Monday 9:00am – 5:00pm

Tuesday 9:00am – 5:00pm

Wednesday 9:00am – 5:00pm

Thursday 9:00am – 7:00pm

Friday 9:00am – 5:00pm

Saturday Closed

Sunday Closed

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64 Lincoln Rd, Essendon, Vic, 3040, AustraliaMap Link

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