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It captures next-of-kin and emergency contact information, cultural identity questions for tailored care, and Medicare and DVA details. 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It also asks which phone number you prefer for test results or surgery phone calls and whether you consent to SMS reminders.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How are next of kin and emergency contact details recorded?",{"text":114,"@type":110},"You must provide the full name, relationship to you, and telephone numbers for your next of kin. There is also an option to tick if the emergency contact is the same as next of kin, and you can complete the separate emergency contact section if needed.",{"name":116,"@type":107,"acceptedAnswer":117},"What does the patient consent and declaration cover?",{"text":118,"@type":110},"It confirms acknowledgment of fees for non-attendance and late cancellations, states the practice is a private billing practice, and assigns responsibility for accounts of children under 16 listed as next of kin. It also explains how personal information may be collected, used, and disclosed under privacy terms, and includes a signature and date.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},307409,1790415591,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},549758252649,"https://ap-avatar.wpscdn.com/avatar/8000253669c5317157?_k=1778319167496531819","We are committed to providing our patients with the best care. Please assist us in doing so by completing your new patient record form:  \nCONTACT INFORMATION  \nTitle:   Given Names:   Surname:    \nPreferred Name:   Date of Birth:  /  /   Gender:    \nResidential Address:    \nSuburb:   Postcode:    \nPostal Address: (if different from above):    \nSuburb:   Postcode:    \nTelephone: (Home)   (Work)   (Mobile)    \nPlease tick preferred phone number for test results/surgery phone calls 􀁆 HOME 􀁆 WORK 􀁆 MOBILE  \nIn addition to other communications we may send you from time to time, we may send you the following types of communications:  \n1. appointment reminders – notifications to you to remind you of upcoming appointment dates with the practice as well as allowing you to confirm your appointment;  \n2. clinical reminders - notifications to you to remind you to contact the practice to arrange appointments for regular clinical check-ups, medical procedures, immunisations due;  \n3. clinical communications - communications to you about your clinical care at the practice such as returned pathology results or clinical messages from the medical practitioner; and  \n[4.](4. health)[ health](4. health) awareness – 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.  \nDo you consent to receiving reminders via SMS? 􀁆 YES 􀁆 NO  \n(If you have an appointment, you will receive the reminder the day before)  \nEmail Address:   Occupation:    \nNEXT OF KIN  \nFull Name:   Relationship to you:   Telephone: (Home)   (Work)   (Mobile)   EMERGENCY CONTACT | Tick if same as next of kin 􀁆  \nFull Name:   Relationship to you:   Telephone: (Home)   (Work)   (Mobile)    \nCULTURAL IDENTITY  \nTo assist with health initiatives – are you Aboriginal and/or Torres Strait Islander?:  \n􀁆 NO 􀁆 YES – Aboriginal 􀁆 YES – Torres Strait Islander 􀁆 YES – Aboriginal and Torres Strait Islander  \nAs Australia is a multicultural society, and to tailor appropriate care, encourage understanding and appreciation between people from different nationalities and cultures – do you identify as someone from a culturally and/or linguistic diverse background?  \nMEDICARE DETAILS  \nMedicare Card No:   Ref No:(on left near name)   Expiry date  /    \nDVA PATIENTS  \nCard Number:   Expiry date  /   Gold / White / Orange OTHER Pensioner Card / Health Care Card / Commonwealth Seniors Health Card Number Card Number:   Expiry date  /    \n􀁆 NO  \n􀁆 YES – please elaborate   ALLERGIES Do you have any allergies? YES 􀁆 NO 􀁆  \n\n| PRODUCT | REACTION | SEVERITY |\n| --- | --- | --- |\n|  |  |  |\n|  |  |  |\n\nHEIGHT AND WEIGHT  \nIf know your height and weight please state below to allow us to get to the issue that brought you in faster and provide you with the best suited care. If it has been a while since these were last measured or you aren’t sure what they are please inform the reception and you will be put you through to see the nurse prior to your first appointment.  \nHeight: (cm)   Weight: (kg)    \nIDENTIFICATION Medicare and non-Medicare holders, please provide identification  \nAdministration use only – identification has been sighted. Administration signature    \nMedicare card 􀁆 Other 􀁆  \nPATIENT CONSENT AND DECLARATION  \nPlease read the Patient Consent and Privacy document and the below information prior to signing. For a more detail version read the copy at the fron of the new patient form clip board.  \n􀁸 I acknowledge that West End Medical charges a fee for non-attendance and late cancellations of less than 2 hours’ notice. Nonpayment of accounts may incur further costs if not paid within 7 days.  \n􀁸 I acknowledge that West End Medical is a Private Billing Practice.  \n􀁸 I am responsible for all accounts of any children under the age of 16 years who I am listed as their next of kin.  \n􀁸 I have","cbCaiv9vU5tETeOn","https://ap.wps.com/l/cbCaiv9vU5tETeOn","pdf",780281,"English","# Contact Information\n# Next of Kin\n# Cultural Identity\n# Medicare Details\n# DVA Patients\n# Allergies\n# Height and Weight\n# Patient Consent and Declaration","[{\"question\":\"What information is collected in the contact information section?\",\"answer\":\"The form requests title, given names, surname, preferred name, date of birth, gender, residential and postal addresses, and telephone numbers. It also asks which phone number you prefer for test results or surgery phone calls and whether you consent to SMS reminders.\"},{\"question\":\"How are next of kin and emergency contact details recorded?\",\"answer\":\"You must provide the full name, relationship to you, and telephone numbers for your next of kin. There is also an option to tick if the emergency contact is the same as next of kin, and you can complete the separate emergency contact section if needed.\"},{\"question\":\"What does the patient consent and declaration cover?\",\"answer\":\"It confirms acknowledgment of fees for non-attendance and late cancellations, states the practice is a private billing practice, and assigns responsibility for accounts of children under 16 listed as next of kin. It also explains how personal information may be collected, used, and disclosed under privacy terms, and includes a signature and date.\"}]","WEM New Patient Information Form 2020 | PDF",1789848887]