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* Date Format: 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone NumberWork NumberMobile NumberEmailSMS Consent Select All Appointments Clinical Communication Clinical Reminders Health Awareness Please TickPreferred Contact Method Home Phone Work Phone Mobile Phone Email SMS Please TickOccupationPast 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 NoType of Veterans CardPlease Select;GoldWhiteCard Expiry Date Format: DD slash MM slash YYYY Pension, or Health Care CardCard Expiry Date Format: DD slash MM slash YYYY Emergency Contact DetailsNext of Kin (Full Name)Contact NumberRelationship to youEmergency Contact (Full Name)Contact NumberRelationship to youDo 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 BackgroundCountry of BirthIs 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 ConsumptionDo you have any other relevant medical conditions?Have you had a Cervical Screening?Please Select;YesNot SureNeverDate of last Pap Smear Date Format: DD slash MM slash YYYY Have you had a Breast Check?Please Select;YesNot SureNeverDate of last Breast Check Date Format: DD slash MM slash YYYY Have you been immunised against Influenza?Please Select;YesNot SureNeverDate of Influenza Vaccination Date Format: DD slash MM slash YYYY Have you been immunised against Pneumococcal?Please Select;YesNot SureNeverDate of Pneumococcal Vaccination Date Format: DD slash MM slash YYYY ConsentAt 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*NameDate Date Format: DD slash MM slash YYYY Upload your PhotoHow did you hear about us?*Please Select;GoogleHealth EngineFamilyFriendOtherPlease Specify