New Patient Form - Adult - Pivotal HealthPivotal Health

New Patient Information Form - Adult (over 16)

Welcome to our practice! We are committed to providing our patients with the best care. To do this it is essential that your health record is kept up to date and is accurate. Could you please assist us by completing the following information?

Title

Gender

Male
Female
Intersex
Rather not disclose

Name

First Middle Last

Date of Birth

Address

Street Address City State / Province / Region ZIP / Postal Code

Home Phone Number

Work Phone Number

Mobile Phone Number

Do you consent to receive appointment reminders via SMS from Pivotal Health? i.e. notifications to you to remind you of upcoming appointment dates with the practice as well as allowing you to confirm your appointment

Yes
No

Do you consent to receive clinical reminders via SMS from Pivotal Health? i.e. notifications to you to remind you to contact the practice to arrange appointments for regular clinical check-ups, medical procedures, immunisations due)

Yes
No

Do you consent to receive clinical communications via SMS from Pivotal Health? i.e. communications to you about your clinical care at the practice such as returned pathology results or clinical messages from the medical practitioner

Yes
No

Do you consent to receive health awareness communication via SMS from Pivotal Health? i.e. communications to you in relation to general health care information and health care services provided by this general practice including notification about changes to our clinic opening hours, and information about health care services provided by this general practice.

Yes
No

Email Address*

Do you consent to receiving emails?

Yes
No

My preferred contact for ALL communication with Pivotal Health is

Phone (voice calls)
Letter
SMS
Email

Did you "Opt Out" of an electronic My Health Record?

Yes
No

Country of Birth

Medicare Number

Reference Number

Please enter a number from 1 to 8.

(number beside your name)

Expiry Date

Veteran Affairs

DVA Gold
DVA White

(Please tick which)

Condition for white (if applicable)

Card Number

Date

Pension Number

Card Number

Expiry Date

Private Health Cover

Yes
No

Hospital
Extras
Hospitals + Extras

Name of Fund

Net of Kin and Emergency Contact

We will only contact you emergency contact in case of Emergency when we are unable to contact you.

Next of Kin (name, relationship and contact phone number)*

(Name, Telephone Number and relationship)

Emergency Contact

(Name, Telephone Number, relationship and other than next of kin that can be contacted in emergencies)

Occupation

Reminder System

Our practice provides our patients with preventative care and early case detection reminders such as immunisation, annual health checks, skin checks and pap smears.

Do you wish to have any relevant health reminders sent to you?

Yes
No

To assist with health initiatives – Are you Aboriginal or Torres Strait Islander:

No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, Aboriginal and Torres Strait Islander

What are the health related goals do you wish to achieve at your first appointment?

*Please note that not all goals may be achieved at your first appointment, the GP will prioritise this list with you and cover what they can in the first appointment,

How did you find out about us?

New Patient Form – Adult

New Patient Form NEW

Step 1 of 5

New Patient Information Form - Adult (over 16)

Medicare Number

Veteran Affairs

Pension Number

Private Health Cover

Net of Kin and Emergency Contact

Reminder System

Your Health History

Past Screening Tests

Allergies

Current Medication

Immunisations

Family History

Lifestyle/Social History

Year	Details

Please specify name	Specialty

Please specify who	Profession

Allergy	Type of Reaction