Polaris Medical Centre – New Patient Registration Form (2025)

NEW PATIENT REGISTRATION FORM

Your information is kept strictly confidential under the Privacy Act 1988.

SECTION 1 – PERSONAL DETAILS

Title

Pronoun

Date of Birth

Age

First Name

Surname

Middle Name

Preferred Name

Sex at Birth

Male Female Binary Other

If Other (Sex at Birth)

Gender Identity If Other (Gender Identity)

Marital Status

Country of Birth

Ethnicity

ATSI

Aboriginal Torres Strait Islander

Occupation

SECTION 2 – CONTACT INFORMATION

Residential Address

Suburb

Postcode

State

Postal Address (if different)

Home Phone

Mobile

Alt Email

Preferred Contact

Mobile Home Phone Email

SMS Reminders

Yes No

SECTION 3 – EMERGENCY & NEXT OF KIN

Next of Kin

Name

Relationship

Phone

Emergency Contact

Name

Relationship

Phone

SECTION 4 – MEDICARE & CONCESSION DETAILS

Medicare No.

Ref No.

Medicare Expiry

Pension / HCC No.

Pension / HCC Expiry

DVA No.

DVA Type

Gold White Orange

DVA Expiry

Private Health Insurer

Member No.

SECTION 5 – MYMEDICARE & E-HEALTH

MyMedicare (Polaris Medical Centre)

Yes No

eHealth Record

Yes No

SECTION 6 – CONSENT & COMMUNICATION

Reminders for preventative care

Yes No

Results mailed to address

Yes No

Third-party information sharing

Yes No

SECTION 7 – TELEHEALTH CONSENT

I consent to telehealth consultations with Polaris Medical Centre. These may be bulk billed or privately billed as per policy.

I agree

Signature (type full name)

Date

SECTION 8 – PATIENT DECLARATION

I declare that the above information is true and correct to the best of my knowledge.

I confirm the above is true and correct.

Signature (type full name)

Date

SECTION 9 – FOR OFFICE USE ONLY

Photo ID sighted Medicare Card sighted Concession Card sighted

Medicare validated

MyMedicare Form completed

Chart No.

Checked by / Staff Name

Entered onto Pracsoft by

Date

Having trouble? Please contact us on (03) 9227 3300 or admin@polarismedicalcentre.com.au