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

    Ethnicity

    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

    History

    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

    
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    Quality Care since 1978

    Lockridge Medical Centre

    Opening Hours

    Monday & Thursday:
    8:00AM – 6:30PM

    Tuesday & Wednesday:
    8:00AM – 6:00PM

    Friday:
    8:00AM – 5.30PM

    Saturday:
    8:30AM – 1.00PM

    Sunday: CLOSED

    Public Holiday: CLOSED