New Patient Registration Form

Contact Details

First Name *

Last Name *

Preferred Name

Date of Birth *

Phone Number *

Email Address *

Occupation *

Sporting/Leisure Activities

Address

Street Address *

Suburb *

Postcode *

Next of Kin

First Name *

Surname *

Relationship *

Their Phone Number *

Health Professionals

Name of your GP

Your GP's Location

Other Health Professionals

Their Location(s)

Medicare & Insurance

Are you privately insured? *

YesNo

Private Insurance Fund Name

Private Insurance Fund Number

Medicare Number *

Reference Number *

Valid Until *

DVA Card Number

Gold Card?

YesNo

Pension Card?

YesNo

TAC/Work Cover Claim Number

Name of Case Worker

Medical History

Please describe your Medical History

Medications & Supplements

Please List Any Other Current Medications

Do you smoke? *

YesNo

If you do smoke, how many a day?

Do you have any allergies or sensitivities? *

YesNo

If so what are they?

Have you ever had any surgery? *

YesNo

How did you hear about COG? *

We respect your right to privacy. All information collected is stored securely and accessed only by our staff. In order to provide the highest standard of care, there are times when we may communicate with your other healthcare providers. In signing this form you consent to the collection and dissemination of information as described. You understand that provision of your medical history is necessary to provide you with effective, safe and efficient treatment. You agree to notify our clinic if you have any changes in your health.

I understand