UNIVERSITY OF MELBOURNE HEALTH SERVICE
NEW PATIENT INFORMATION FORM
This information is used for admin and healthcare staff to correctly identify, invoice and assist you. It is entirely
confidential. If you have any questions, please do not hesitate to ask admin.
Title ☐ Miss ☐ Ms ☐ Mrs ☐ Mr ☐ Mx ☐ Dr ☐ Other (specify) ________________
Given name/s
Last
(name/s on
name
Medicare/OSHC)
Date of
Known as (preferred name)
Birth
What was your SEX recorded at birth? ☐ Female ☐ Prefer not to say
This information is collected to inform the care you receive. ☐ Male ☐ Another term (specify) ______________________
How do you describe your GENDER?
☐ Female ☐ Non-binary
Gender refers to current gender, which may be different to sex
recorded at birth and/or what is indicated on legal documents. ☐ Male ☐ Other (specify) ____________________
Pronouns
☐ She/her ☐ He/him ☐ They/them ☐ Prefer not to say ☐ Other (specify)_______________________
(tick all that apply)
Mobile No. Home Phone No.
Email
address
Are you happy to receive preventative care and early detection reminders via SMS? ☐ Yes ☐ No
Address
in Melbourne
Suburb Postcode
Domestic Students International Students
OSHC: ☐ Bupa ☐ Allianz (OSHC Worldcare) ☐ Other
Medicare number ______________________________
Membership number: ___________________ ☐ Family ☐ Single
Ref # ________ Expiry date _______________
Policy start date: ______________ End date: ________________
☐ Unimelb Student ☐ Dependent of student or staff member
What is your association with Melbourne Uni?
☐ Unimelb Staff ☐ Student of another University
Student number Uni faculty
(if applicable) (if applicable)
Do you ☐ Aboriginal ☐ Neither What is your
identify as: ☐ Torres Strait Islander ☐ Both country of birth?
First name: Relation to you:
Emergency contact
MUST be in Australia
Phone number:
How did you find out about the Health Service?
Health Information Collection and Use Consent Form
Health Service, University of Melbourne
As a patient of our medical practice we require you to provide us with your personal details and a full medical
history, so that we may properly assess, diagnose, treat and be proactive in your health care needs.
We aim to protect the privacy and secure storage of your health information. You can request a copy of our
privacy policy, which includes information about the collection, use and disclosure of your health information.
We require your consent to collect personal information about you and to use the information you provide in the
following ways. Please read this consent form carefully, and sign where indicated below.
x Administrative purposes in running our medical practice.
x Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
x Disclosure to others involved in your healthcare including treating doctors and specialists outside this
medical practice. This may occur though referral to other doctors, or for medical tests and in the reports
or results returned to us following referrals.
x Disclosure to other doctors in the practice, locums etc. attached to the practice for the purpose of patient
care and teaching.
x For research and quality assurance activities to improve individual and community health care and
practice management. Usually information that does not identify you is used but should information that
will identify you be required you will be informed and given the opportunity to “opt out” of any
involvement.
x To comply with any legislative or regulatory requirements e.g. notifiable diseases.
x For reminder letters which may be sent to you regarding your health care and management.
You can decline to have your health information used in all or some of the ways outlined above but it may
influence our ability to manage your health care to provide the best outcome for you.
I have read the information above and understand the reasons why my information must be
collected.
I understand that I am not obliged to provide any information requested of me, but failure to
do so may compromise the quality of health care and treatment given to me.
I am aware of my rights to access the information collected about me, except in some
circumstances where access may be legitimately withheld. I will be given an explanation in
these circumstances.
I understand that if my information is to be used for any other purpose other than set out
above, my further consent will be obtained.
I consent to the handling of my information by the practice for the purpose set out above,
subject to any limitations on access or disclosure of which I notify this practice.
OR
I am unsure and would like to discuss this further with someone from the medical practice
before I sign.
Patient’s name: …………………………………… Date: ………………
Patient’s signature: ………………………………
Signed as Guardian for child: ………………………………
Name: (printed) ……………………………………
