Easy to find numbers

  • Medical Centre Appointments:
    (08) 6278 2555
  • After Hours Locum Doctor:
    08 9321 9133
  • Life Threatening Emergencies
    000
Patient Registration 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:

Do you give permission for the practice to access and record your IHI number?  Yes  No

Marital Status:  Single  De facto  Divorced  Married  Widowed

To assist with health initiatives - are you:
 Yes - Aboriginal  Yes - Torres Strait Islander  Yes - Aboriginal & Torres Strait Islander  Other

Next of Kin

Emergency Contact (Name and Telephone number of the person we can contact if needed)

Emergency Contact (Practice/GP Name and Address)

Will Lockridge Medical Centre be your Regular GP Practice?  Yes  No
Interpreter required:  Yes  No

Social History

 NO - Never Smokeds NO - Ceaseds  YES - CURRENTLY
Your health history - do you have or have you had a history of?  Operations  Asthma  Diabetes  Hypertension  Chronic illness  Other
Family History - have any members of your family had:  DIABETES  ASTHMA  HEART DISEASE  MENTAL ILLNESS  CANCER
Do you have any allergies or are you sensitive to drugs or dressings:  Yes  No
Immunisations - have you had the following immunisations?  Tetanus booster  Hepatitis B  Hepatitis A  Influenza  Pneumococcal  Polio
Children's immunisations - if completing this form for a child are their immunisations up to date?  Yes  No
Current medications (including over the counter medications, vitamins and minerals):