Patient Registration Form

To prepare for your upcoming appointment, please complete all fields and submit this form at least 24 hours before your appointment. This form will be securely kept in your patient files.

You can partially complete and SAVE, and when complete please click SUBMIT.

If you have any queries or require assistance with this form, please call 0402 166 415.

1nspire Clinic is based in Rockhampton QLD, 4700.

PATIENT DETAILS

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

MaleFemaleIndeterminate/Intersex/Unspecified

English is a Second Language

YesNo

Please note that 1nspire Clinic does not offer a translator service. Please bring a person with you to the appointment who can translate for you.

What is/was your occupation?

Ethnicity

Are you of Aboriginal or Torres Strait Islander origin?

AboriginalTorres Strait Islander

PATIENT CONTACT DETAILS

Home Phone

Mobile Phone *

Work Phone

Email

Address *

Postcode *

City / Suburb

State *

EMERGENCY CONTACT DETAILS

Name *

Address

Postcode

City / Suburb

State

Home Phone

Mobile Phone *

Email

Work Phone

NEXT OF KIN CONTACT DETAILS

Is the next of Kin same as your emergency (if yes, you do not need to fill this section)

YesNo

Next of Kin - Name

Next of kin - Email

Next of kin Home Phone

Next of kin - Mobile Phone

Best way to contact your next of Kin

Home PhMobile PhWork Ph

REFERRING DOCTOR

Referring Doctor’s Name

Address

Family Doctor/ Regular General Practitioner Name (if different to referring doctor)

Address

MEDICARE

Do you use a different name on your Medicare card?

YesNo

If you use an Alias please write the Alias name & surname

Medicare First Name

Medicare Surname

Medicare Card No.

Expiry

IRN

Medicare Address (if different to your residential address)

PRIVATE HEALTH INSURANCE

Do you have private Medical insurance

YesNo

Provider

Membership No.

Expiry

Healthcare Number (e.g. 01)

PENSION / HCC / DVA Card

Do you have an aged pension card, healthcare card or a DVA card

YesNo

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

DVA Card Type

GoldWhite

DVA No.

SMOKING HISTORY

Do you currently smoke?

YesNoContemplating giving up

If Yes,what age did you start?

Number of cigarettes a day?

CURRENT PROBLEMS

If you have sputum, are you coughing up any blood?

Frank bloodSpotsStreaking

Have you recently experienced any unexplained

Weight LossBack Pain Night Sweats

EXISTING MEDICAL HISTORY

Please state your primary concern/condition (i.e. bronchiectasis, COPD, cystic fibrosis)

Please list any allergies

CURRENT MEDICATION

Please list current prescribed and over the counter medications

SIGNATURE

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

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