Level 1, 109 Honour Avenue
Chelmer QLD 4068

P: 07 3162 5310 F: 07 3077 7153
E: reception@heartofaustralia.com
W: www.heartofaustralia.com.au

PATIENT INFORMATION FORM

Title:

Given Name:

Surname:

Date of Birth:

Gender:

MaleFemale

Ethnicity:

AboriginalTorres Strait IslanderCaucasianOther

Wheelchair Access Required:

YesNo

Contact Details

Home Ph:

Work Ph:

Mobile Ph:

Preferred Contact Number:

HomeWorkMobile

Would you like to receive SMS reminders:

YesNo

Email:

Residential Address

Street address

City

State

Postcode

Postal Address is same as Residential Address

Postal Address

Street address

City

State

Postcode

Occupation:

Job Title:

Medicare

Number:

Reference:

Expiry:

Department of Veteran Affairs

Card Number:

Card Type:

GoldSilverWhite

Pension

Pension Type:

Pension Number:

Private Health

Health Fund:

Member Number:

GP Details

GP Name:

Practice Name and Address:

Emergency Contact Person OR Parent/Guardian

Name:

Relationship to Patient:

Home Ph:

Work Ph:

Mobile Ph:

PRIVACY STATEMENT

I authorise the release of my medical records from existing and past health care providers to my treating doctor for my current care and future treatment.

Signature:

Draw signature|Type signatureClear

Date:

Privacy Notes: This information is required to enable us to accurately maintain our records and to ensure that patients
are correctly billed. The authorisation will allow us to access your previous medical records needed to assist with your
assessment and treatment. Pho ne numbers will be used to confirm appointments. If you have any concerns regarding
this, please discuss them with the treating doctor during your consultation.