New Patient Form

We are committed to providing our patients with the best care. To do this it is essential that your health record is kept up to date and accurate. Could you please assist us by completing the following:

SingleDe factoDivorcedMarriedWidowed

Interpreter required:YesNo

Do you give permission for the practice to access and record your IHI number?YesNo


Yes - AboriginalYes - Torres Strait IslanderYes - Aboriginal & Torres Strait IslanderOther

Next of Kin

Emergency Contact

Practice/GP Contact

Will Lockridge Medical Centre be your Regular GP Practice?YesNo


NO - Never SmokedNO - CeasedYES - CURRENTLY

Current medications (including over the counter medications, vitamins and minerals):

Do you have or have you had a history of?OperationsAsthmaDiabetesHypertensionChronic illnessOther

Do you have any allergies or are you sensitive to drugs or dressings:YesNo

Family History - have any members of your family had:DIABETESASTHMAHEART DISEASEMENTAL ILLNESSCANCER

Children's immunisations - if completing this form for a child are their immunisations up to date?YesNo

Immunisations - have you had the following immunisations?Tetanus boosterHepatitis BHepatitis AInfluenzaPneumococcalPolio