Patient Registration - Willowglen Medical Centre

PLEASE NOTE: THESE FORMS ARE NOT FUNCTIONAL YET.
WE’RE STILL TESTING THEM HEAVILY FOR PROPER COMPLIANCE. PATIENTS DO NOT USE THEM FOR NOW.

New patients are encouraged to register online prior to their first visit to Willowglen Medical Centre for a faster check-in experience at reception. We encourage you to read our Privacy Policy before you proceed.

The forms might seem extensive, but please don’t fret. Most of the fields are optional.

Do you have valid Medicare? Select this form, please.

Let’s start with the Title *

Mr.
Mrs.
Ms.
Dr.

Your First Name *

Your Middle Name

Optional

Your Surname

Date of Birth *

Gender *

Male
Female
Other

Medicare Information *

Enter number without spaces.

Valid to Date *

The date of expiry of your Medicare.

IRN *

The IRN is required that it be included on Medicare claim forms

Please provide your contact information.

Your contact details, important information

Mobile *

Your mobile number

Email *

Your email

Residential Address *

Address Line 1

Address Line 2

City

State / Region

Postcode

Postal address and landline numbers are optional.

Provide postal address only if it is not the same as your home address; otherwise just leave it blank.

Postal Address (optional)

Address Line 1

Address Line 2

City

State / Province/ Region

Postcode

Country

You need to fill this form ONLY IF your home address is not your postal address.

Home Phone

Optional

Work Phone

Optional

In case of an emergency, who is best to be contacted? Required Information.

Provide an alternative and reachable contact information

A relative or colleague would make the ideal choice.

Contact Person *

Name of the contact

Contact Mobile *

Emergency contact mobile number

Relationship with You *

How does he/she related to you?

A Second Mobile (optional)

This number is optional, but a good idea

A Third Mobile (optional)

Optional, but an even good idea

The following data needs to be filled ONLY if applicable. Fields are not for you if you're not a cardholder.

Data related to various card holders only. If you’re not a cardholder, simply scroll through.

Pension Card Number

Pension card details

Expiry Date of Your Pension Card

Pension card expiry date

Healthcare Card Number

Healthcare card details

Expiry Date of Your Healthcare Card

Healthcare card expiry date

Veteran’s Affair (DVA-Number)

DVA number information

Expiry Date of Your DVA Card

DVA card expiry date

Private Health Fund Card

Private health fund card information

Expiry Date of Your Private Health Fund Card

Private health fund card expiry date

Overseas Student or Visitor Insurance

Insurance information for Visa holders

The following are all optional. All are pre-selected as NO for your convenience.

May not be applicable to you, Still, we suggest you read and proceed. Please do check.

Maybe.

Would you like to register for My Health Record by providing 100 points of identification?

Are you of Torres Strait Islander Origin?

Yes, I am

Check here if you’re

Do you require a translator or help with filling in this form?

Yes, I do

Check here to let us know

Are you of Aboriginal?

Yes, I am

Check here if you’re Aboriginal

Do you identify with any cultural background?

Yes, I do

Check here if you do so

WILLOWGLEN MEDICAL CENTRE – NEW PATIENT HEALTH SUMMARY

All are pre-selected as NO for your convenience.

Are you currently taking medication?

Yes, I do

Medication of any kind would qualify

If you do, please provide details of your medication below.

Your current medication

Do you have known Allergies or Sensitivities?

Yes, I have

Even if you suspect something, tell us

If you do have, please provide details of your allergic condition below.

Allergies or Sensitivities

Have you ever had or have now any of the following conditions?

All are pre-selected as NO for your convenience.

High / Low Blood Pressure?

Yes, I’m hypertensive/hypotensive

Asthma?

Yes, I’m asthmatic

Heart Disease/Cardiomyopathy?

Yes, I’m cardiopath

Arthritis?

Yes, I’m arthritic

Back Pain/Problems?

Glaucoma?

Hypothyroidism/Hyperthyroidism?

Digestive Problems?

Depression?

Yes, I’ve depressive disorder

Kidney/Renal Problems?

Yes, I’ve certain KD

Obesity?

Please fill this part of the form to the best of your knowledge.

Questions are relevant only if you click yes.

Are you an ex-smoker?

Yes, I am

How many years has it been since you last smoked?

Less than 1 year is 0.

Are you a smoker?

Yes, I do

How many years has it been since you started smoking?

Less than 1 year is 0.

Do you drink alcohol?

Yes, I do

How many years has it been since you started drinking alcohol?

Less than 1 year is 0.

Place a check for YES, leave blank for NO.

even if you have the slightest doubt about a certain condition, do please check

Diabetes?

Yes, I’m diabetic

Shortness of Breath?

Yes, I’ve dyspnea

Epilepsy?

Yes, I’m epileptic

Cancer?

Yes, I’m a survivor

🙂

Parkinson’s Disease?

Multiple Sclerosis?

Osteoarthritis?

Bipolar/Mood Disorders?

Schizophrenia?

Yes, I have this condition

Eating Disorders?

Please specify other previous conditions/illnesses, if any.

Any doubt, request or message related to this form?

Please specify significant immediate family history, if any.

The following two questions are for our female patients only.

Have you had a pap smear in the last 2 years?

Check if you answer yes

Female-specific question.

Have you ever had a mammogram?

Check if you answer yes

Female-specific question.

One last question. Would you like to receive SMS / Email from our practice?

Reminders, Newsletters and updates. Check here, it helps

Before you submit the form, kindly read the terms and if you agree, check the signature box below.

Willowglen Medical Centre follows the RACGP standards and guidelines. All information provided is treated strictly confidential. Willowglen Medical Centre participates in the National State & Territory Reminder System. I consent to the release of appropriate information to Specialists and Allied Health Professionals to facilitate my health care if needed. I consent to be contacted through mobile/home phone and letters. If I change contacts details it is my responsibility to inform Willowglen Medical Centre, so my records can be updated. I consent to assign my or as legal guardian my wards Bulk bill benefit to Willowglen Medical for each consultation with them. Some consultations do incur fees. Please ask at reception for a detailed list of any consultation fees. Some services which your doctor will discuss with you during your consultation e.g. Vaccinations/ Procedures /Pre-Employment Medicals/ Commercial Drivers License / Investigations could also incur an additional fee.

* I consent for Willowglen Medical Centre contact "Next of Kin" or person named IF AN EMERGENCY SHOULD ARISE.

*Must reside in Australia

BY CHECKING THE CHECKBOX BELOW, YOU ARE AGREEING THE TERMS. *

I AGREE and I CONSENT

Message

You don’t have Medicare? No worries, this form is for you.

Let’s start with the Title *

Mr.
Mrs.
Ms.
Dr.

Your First Name *

Your Middle Name

Optional

Your Surname

Date of Birth *

Gender *

Male
Female
Other

Please provide your contact information.

Your contact details, important information

Mobile *

Your mobile number

Email *

Your email

Residential Address *

Address Line 1

Address Line 2

City

State / Region

Postcode

Postal address and landline numbers are optional.

Provide postal address only if it is not the same as your home address; otherwise just leave it blank.

Postal Address (optional)

Address Line 1

Address Line 2

City

State / Province/ Region

Postcode

Country

You need to fill this form ONLY IF your home address is not your postal address.

Home Phone

Optional

Work Phone

Optional

In case of an emergency, who is best to be contacted? Required Information.

Provide an alternative and reachable contact information

A relative or colleague would make the ideal choice.

Contact Person *

Name of the contact

Contact Mobile *

Emergency contact mobile number

Relationship with You *

How does he/she related to you?

A Second Mobile (optional)

This number is optional, but a good idea

A Third Mobile (optional)

Optional, but an even good idea

The following data needs to be filled ONLY if applicable. Fields are not for you if you're not a cardholder.

Data related to various card holders only. If you’re not a cardholder, simply scroll through.

Pension Card Number

Pension card details

Expiry Date of Your Pension Card

Pension card expiry date

Healthcare Card Number

Healthcare card details

Expiry Date of Your Healthcare Card

Healthcare card expiry date

Veteran’s Affair (DVA-Number)

DVA number information

Expiry Date of Your DVA Card

DVA card expiry date

Private Health Fund Card

Private health fund card information

Expiry Date of Your Private Health Fund Card

Private health fund card expiry date

Overseas Student or Visitor Insurance

Insurance information for Visa holders

The following are all optional. All are pre-selected as NO for your convenience.

May not be applicable to you, Still, we suggest you read and proceed. Please do check.

Maybe.

Would you like to register for My Health Record by providing 100 points of identification?

Are you of Torres Strait Islander Origin?

Yes, I am

Check here if you’re

Do you require a translator or help with filling in this form?

Yes, I need

Check here to let us know

Are you of Aboriginal?

Yes, I am

Check here if you’re Aboriginal

Do you identify with any cultural background?

Yes, I do

Check here if you do so

WILLOWGLEN MEDICAL CENTRE – NEW PATIENT HEALTH SUMMARY

All are pre-selected as NO for your convenience.

Are you currently taking medication?

Yes, I do

Medication of any kind would qualify

If you do, please provide details of your medication below.

Your current medication

Do you have known Allergies or Sensitivities?

Yes, I have

Even if you suspect something, tell us

If you do have, please provide details of your allergic condition below.

Allergies or Sensitivities

Have you ever had or have now any of the following conditions?

All are pre-selected as NO for your convenience.

High / Low Blood Pressure?

Yes, I’m hypertensive/hypotensive

Asthma?

Yes, I’m asthmatic

Heart Disease/Cardiomyopathy?

Yes, I’m cardiopath

Arthritis?

Yes, I’m arthritic

Back Pain/Problems?

Glaucoma?

Hypothyroidism/Hyperthyroidism?

Digestive Problems?

Depression?

Yes, I’ve depressive disorder

Kidney/Renal Problems?

Yes, I’ve certain KD

Obesity?

Yes.

Please fill this part of the form to the best of your knowledge.

Questions are relevant only if you click yes.

Are you an ex-smoker?

Yes, I am

How many years has it been since you last smoked?

Less than 1 year is 0.

Are you a smoker?

Yes, I am

How many years has it been since you started smoking?

Less than 1 year is 0.

Do you drink alcohol?

Yes, I do

How many years has it been since you started drinking alcohol?

Less than 1 year is 0.

Place a check for YES, leave blank for NO.

even if you have the slightest doubt about a certain condition, do please check

Diabetes?

Yes, I’m diabetic

Shortness of Breath?

Yes, I’ve dyspnea

Epilepsy?

Yes, I’m epileptic

Cancer?

Yes, I’m a survivor

🙂

Parkinson’s Disease?

Multiple Sclerosis?

Osteoarthritis?

Bipolar/Mood Disorders?

Yes, I’ve mood swings

Schizophrenia?

Yes, I have this condition

Eating Disorders?

Please specify other previous conditions/illnesses, if any.

Any doubt, request or message related to this form?

Please specify significant immediate family history, if any.

The following two questions are for our female patients only.

Have you had a pap smear in the last 2 years?

Check if you answer yes

Female-specific question.

Have you ever had a mammogram?

Check if you answer yes

Female-specific question.

One last question. Would you like to receive SMS / Email from our practice?

Reminders, Newsletters and updates. Check here, it helps

Before you submit the form, kindly read the terms and if you agree, check the signature box below.

* I consent for Willowglen Medical Centre contact "Next of Kin" or person named IF AN EMERGENCY SHOULD ARISE.

*Must reside in Australia

BY CHECKING THE CHECKBOX BELOW, YOU ARE AGREEING THE TERMS. *

I AGREE and I CONSENT

Message

If you’re not interested in filing a form online, you can still download our offline form.