New patients

New patient form

Please complete the following form and submit when finished. We will have your file ready for your appointment.

Before you start

Filling this in before your visit saves you time at the front desk and means your doctor has your history in front of them when you sit down. It takes about ten minutes. A couple of things are worth having next to you.

Your Medicare card

You will need the card number, the reference number beside your name, and the expiry date. Have any Pension, Health Care or DVA card handy too.

Your GP and next of kin details

The name of your usual GP and their practice, and a contact name and phone number for your next of kin.

About ten minutes

The form is completed in one sitting, so it is worth starting when you have a clear run at it. Your answers are not saved if you close the page part way through.

Completing this form is not a booking. If you do not yet have an appointment, please book online or call (02) 4960 8255. No GP referral is required to see us.

Your details

Fields marked (required) must be completed before the form can be submitted. Everything else is helpful but optional, and reception can fill in the gaps with you when you arrive.

Patient details

Please choose one

First name

Last name

Known as

The name you would like us to call you.

Date of birth

If the patient is under 18, please complete the guardian details below.

Guardian details

Only needed if the patient is under 18.

Guardian first name

Guardian last name

Guardian's date of birth

Guardian's Medicare card number

Medicare reference no.

The number next to the name on the card.

Expiry date

As shown on the card, for example 08/2029.

Contact details

Address

Postal address

Only if it is different from the address above.

Home phone number

Work phone number

Mobile phone number

Next of kin

For contact purposes.

Next of kin name

Next of kin contact phone number

Next of kin relationship to patient

Your usual GP

GP name and practice

Medicare and concession cards

Please bring all of your cards with you and present them to reception for confirmation.

Medicare card number

Medicare reference no.

The number next to your name on the card.

Expiry date

As shown on the card, for example 08/2029.

Pension card number

Expiry date

DVA, Veteran's Affairs number

Expiry date

Please present all cards to reception for confirmation when you arrive.

Medical history

Please complete this section if it is not on your referral, if it is different from your referral, or if you have no referral.

Past illnesses and operations

Family history of melanoma

Please note any previous family history of skin cancer. If you do not know, please write 'Not known'.

Any lesions of concern

Please note any specific spots that you are concerned about.

Current medications

Allergies

Do you have a pacemaker?

YesNo

Consent

Release of medical information

I give my consent for Newcastle Skin Medical Centre to release medical information in regard to myself to my referring practitioner, other treating doctors and hospitals where I have been treated.

YesNo

Photography consent

I agree that images taken by my doctor on behalf of Newcastle Skin Medical Centre may be placed in my electronic file for future reference.

YesNo

Acknowledgements

Please acknowledge each of the following by ticking the box. All three are required.

I acknowledge that any additional procedures will incur an additional fee and I can discuss this with the administration staff.I acknowledge that any pathology will incur an invoice from the pathology company, unless I possess a concession card such as a Health Care Card, Pension card or Veterans card.I acknowledge that all information provided herewith is true and correct to the best of my knowledge.

Today's date

Or call (02) 4960 8255

How we handle your information

The details you provide here go to the practice team at Newcastle Skin Medical Centre and are used to create and maintain your patient record and to provide your care. Your Medicare and concession card details are collected so that we can claim any rebates you are entitled to. We do not use this information for marketing and we do not add you to any mailing list. Your information is handled in line with the Privacy Act 1988 and the Australian Privacy Principles. If you would prefer to give us these details in person or over the phone, please call (02) 4960 8255 instead.

Would you rather not fill this in online?

That is completely fine. Call the practice and reception will take your details over the phone, or arrive about ten minutes early and complete a paper copy at the front desk.

(02) 4960 8255

Not sure what to expect on the day? Read our patient information.