New Patient Registration – Ravenswood Family Practice

Ethnicity
Australia 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)
Other Cultural Background
Country of Birth
Is English your first language?
Do you require an Interpreter?
Please specify language

Consent
At the Ravenswood Family Practice we strive to provide high quality care, appropriate to meet our client's health requirements. By becoming a patient of Ravenswood 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 Ravenswood 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
Date Format: DD slash MM slash YYYY
Upload your Photo
How did you hear about us?*
Please Specify

New Patient Registration Form