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Willowglen Medical Centre - New Patient Online Registration.


Please use the form below to register with us. The fields marked by * are required. Others are optional. Works best in Chrome/Firefox/Safari browsers and iOS/Android devices (recommended).

IMPORTANT: before you proceed please ensure a lock icon is being displayed along with www.willowglenmedical.com.au in your browser address bar above.

Gender?*

Male
Female
Transgender

The following card data needs to be filled ONLY if applicable.

Please provide your contact info.

Is your Home address not your Postal Address?

Let me enter a separate postal address.

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

If you are not registered for My Health Record would you like to do so by providing us with 100 points of identification?

Check here to initiate

Are you of Aboriginal?

Check here if you're Aboriginal.

Are you of Torres Strait Islander Origin?

Check here if you are.

Do you identify with any Cultural Background?

Check here if you do so.

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

Check here to let us know.

Would you like to receive SMS / Email Reminders / Newsletters/ updates from our practice?

Check here, it helps.

How did you hear about our clinic?


WILLOWGLEN MEDICAL CENTRE - NEW PATIENT HEALTH SUMMARY
Please fill this part of the form to the best of your knowledge.

Are you currently taking medication?

Check here if you do so.

Do you have known Allergies or Sensitivities?

Check here if you have.

Have you ever had or have now any of the following conditions? Place a check for YES, leave blank for NO.

High Blood Pressure?

Check here if you've High BP.

Diabetes?

Check here if you're Diabetic.

Asthma?

Check here if you've Asthma.

Shortness of Breath?

Check here if you've this condition.

Heart Disease/Cardiomyopathy?

Check here if you've Heart Disease.

Epilepsy?

Check here if you're Epileptic.

Arthritis?

Check here if you're Arthritic.

Cancer?

Check here if you're a Cancer patient.

Back Pain/Problems?

Check here if you've Back Pain issues.

Parkinson’s Disease?

Check here if you've Parkinsons.

Glaucoma?

Check here if you've Glaucoma.

Multiple Sclerosis?

Check here if you've Multiple Sclerosis.

Hypothyroidism?

Check here if you've Hypothyroidism.

Osteoarthritis?

Check here if you've Osteoarthritis.

Digestive Problems?

Check here if you've Digestive Problems.

Bipolar/Mood Disorders?

Check here if you've Bipolar/Mood Disorders.

Depression?

Check here if you've Depression.

Schizophrenia?

Check here if you're Schizophreniac.

Kidney/Renal Problems?

Check here if you've Kidney Problems.

Eating Disorders?

Check here if you've Eating Disorders.

Obesity?

Check here if you're Obese.

Are you a smoker?

Check here if you smoke.

Are you an ex-smoker?

You quit smoking? Check here.

Do you drink alcohol?

Check here if you do.

Female Questions

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

Check here if you answer yes.

Have you ever had a mammogram?

Check here if you answer yes.

Do you have any message for the Clinic Office?

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 contact "Next of Kin" OR PERSON NAMED IF AN EMERGENCY SHOULD ARISE.
(*Must reside in Australia)

By checking here you are agreeing the terms.
Sending...
Your registration has been submitted, Thank you!
You may now proceed to book an appointment online:
Alternatively you may use this link.
We are open from 8am to 5pm (Weekdays), 9am to 1pm (Saturdays). The Clinic Landline is (07) 4670 9411.