Patient Details | Dr Benedict Mackay

Your Information

Title

Full name (as per Medicare Card)

Date of birth

Address

Suburb

State

Postcode

Phone number

Mobile

Email address

Next of kin - Name

Next of kin - Relationship

Next of kin - Phone number

Insurance & Medicare Details

Medicare number

Reference number

Expiry date

Health insurance fund

Membership number

Reference number

DVA card number

DVA card colour

HCC / Pension number

Expiry Number

Workcover approval number

Employer Details

Employer phone

GPs Details

Referring Doctor

Usual GP (if different from Referring Doctor)

Address of GP

GP Phone number

Other Medical Practitioners – Are there any other medical Practitioners you would like to have copied on correspondence?

Name

Address

Name

Address

Consent to collect patient information

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will use the information in the following ways:

Administrative purposes in running our medical practice
Billing purposes, including compliance with Medicare and Health Insurance Commission requirements
Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you

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Your Information

Insurance & Medicare Details

GPs Details

Patient Medical History