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info@harboursidemedical.com.au

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New Patient Form

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New Patient Form

New Patient Information

Title

Mr

Mrs

Ms

Miss

Master

Other

Gender

Male

Female

Are you Aboriginal or Torres Strait Islander

Yes

No

Please circle if you have one (or multiple) of the following as it may entitle you to reduced prescription costs:

Healthcare Card

Pension Concession Card

Senior Card

Other

Emergency Contact

Personal Information

Smoking status:

Non-smoker

Ex-smoker

Smoker

Alcohol drinking status:

Non-drinker

Drinker

Allergies:

No

Yes

Have you had any past medical problems?

No

Yes

Have you had any operations?

No

Yes

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Harbourside Medical Centre

Harbourside Medical Centre is OPEN for face to face consultations. We also offer Bulk-billing GP PHONE consultations if you are unable or wish not to attend the centre. If you prefer a phone consultation, please select your 'Appointment Type' as 'Telehealth' when booking online or call 02 9166 9940. **Please note: we do not provide Telehealth consultations for New Patients.

***Due to COVID-19, please ensure you wear a facemask when attending the Medical Centre***