KINDLY FILL IN THIS FORM BEFORE YOUR APPOINTMENT

NEW PATIENTS FORM

To make the process as simple as possible please download our new patient form and complete the details prior to your first appointment.

Simply hand the form to reception when you arrive for your appointment.

DOWNLOAD PATIENT FORM

NEW PATIENTS FORM

Step 1 of 3

Personal Details
Title
First
Family Name*
Given Names*
Preferred Name
Date of Birth*
DD slash MM slash YYYY
Gender*
- Male
- Female
Contact Details
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home No.
Work No.
Mobile No.*
Consent to recieve SMS*
- Yes
- No
Email*
Cultural Background
Are you of Aboriginal / Torres Strait Islander origin? (Mark with X)*
- No
- Aboriginal
- Torres Strait Islander
- Both Aboriginal And Torres Strait Islander
What is your ethnicity? (Australian / Indian / Chinese / Greek, etc.)*
Where is your Country of Birth?*
How did you hear about Medicross?
Insurance Details
Medicare No.*
Ref No.
Expiry Date*
DD slash MM slash YYYY
Pension Card No.
Expiry Date
DD slash MM slash YYYY
Healthcare Card No.
Expiry Date
DD slash MM slash YYYY
DVA No.
Next of Kin
Name*
First
Surname*
Relationship*
Contact No.*
Emergency Contact
Same Kin
- Tick here if same as Next of Kin
Name*
First
Surname*
Relationship*
Contact No.*
Family (Children Under 16 Only)
Name
First
Medicare Ref No.
D.O.B
DD slash MM slash YYYY
Gender
Name
First
Medicare Ref No.
D.O.B
DD slash MM slash YYYY
Gender
Name
First
Medicare Ref No.
D.O.B
DD slash MM slash YYYY
Gender

BY BECOMING A PATIENT OF MEDICROSS AND SIGNING BELOW I HAVE READ AND AGREE TO THE FOLLOWING:
- Standard appointments are 10 minutes and generally cover one health concern. If you have more than one health concern, a complex health issue or require a longer appointment for any other reason please notify reception at the time of booking. A separate appointment must be made per person/family member. This will assist the doctors with running on time.
- An appointment must be made with a doctor to obtain results, repeat prescriptions or referrals. Results will not be given over the phone.
- Please ensure mobile phones are turned off during the consultation.
- Patients that fail to attend an appointment without notice may incur a $70 fee and will be unable to attend the practice until the account is paid.
- Patients who are late to their appointment may have to wait until other patients who arrived on time are seen or in some cases reschedule the appointment altogether; this is at the discretion of the doctor.
- Doctors at this practice do not prescribe schedule 8 drugs and have a no-tolerance policy to doctor shoppers and drug seekers. Doctors have the right to refuse the request for prescription drugs.
- This practice has a no-tolerance policy for aggressive or abusive behaviour. Patients who are physically or verbally aggressive to staff will be banned from the practice at the discretion of the doctor or practice manager.
- It is at the discretion of the doctor and practice staff to provide personal health information to parents/guardians of patients under the age of 16. All patients 16 and over are considered adults and information will not be disclosed to parents/guardians/friends/spouse without permission from the patient. If you would like to nominate a person to have access to your health information and communicate with us on your behalf please ask reception for a Third Party Access Consent form.
- The Practice has a Privacy Policy in place which is available on request. This policy will state how we will deal with all personal and sensitive information which includes health information in a confidential and professional manner.
- Our practice uses reminder systems to help you maintain your health. The practice may send reminders by post, email and/or telephone for procedures such as Vaccinations, Pap Smears and other Health Services. Our practice also sends information to the Australian Childhood Immunisation Register, Pap Smear Register and Primary Health Care Network (deidentified information).
- I understand - by indicating by signing below - that the Practice is authorised on my behalf to use my relevant personal health information and I am free to withdraw my consent at any one time by verbal or written notification.
I hereby consent to this policy Agreement
Name of Patient*
First
Signature of Patient (Adding your name here serves as a signature.)*
Print Name & Signature of Parent/Guardian (If Under 16)*
First
Email*
Medical Locations*

NEW PATIENTS

Medicross Medical provides quality medical care to local communities. Each of our Medical Centres have professional doctors, allied health professionals, practice nurses and support staff all focused on providing the best health outcomes for our patients. With 15 Local Medical Centres across South East Queensland we are your first choice for Local Medical Care.

Patient Privacy: This practice protects your personal health information to ensure it is only available to authorised staff members for the intended purposes and to comply with the Privacy Act. To obtain a copy of our Privacy Statement or your medical records, please ask your local Medicross Practice.

ONLINE
APPOINTMENTS

You can book your next appointment online!

Medicross uses the Health Engine appointment system to allow our patients to book an appointment online anytime. It’s simple to use – select your doctor and appointment time and you are done. A reminder for your appointment date and time will be sent to you.

MEDICAL RECORDS TRANSFER

We can arrange for your medical records to be transferred

Simply speak to the reception staff ay your local Medicross Medical centre and they will arrange for your Medical Records to be transferred across for your new Doctor. The process is simple and only takes 2 minutes to complete.

AFTER
HOURS

For after hours medical care please contact the National Home Doctor Service on
13 74 25

BOOK AN APPOINTMENT WITH MEDICROSS MEDICAL

Medicross Medical looks forward to taking care of your health. We are compassionate about people and passionate about medicine. First find your nearest Medicross location to make your online booking.

FIND MY MEDICROSS LOCATION

KINDLY FILL IN THIS FORM BEFORE YOUR APPOINTMENT

NEW PATIENTS FORM

Step 1 of 3

ONLINE APPOINTMENTS

You can book your next appointment online!

MEDICAL RECORDS TRANSFER

We can arrange for your medical records to be transferred

AFTER HOURS

ONLINE
APPOINTMENTS

AFTER
HOURS