Pre-appointment Client Form

Step 1 of 18

Are you a new patient to our practice?*
- Yes
- No

We are committed to protecting your privacy and know it is important for you to understand how your information is handled.
In submitting the information contained in this form, you:*
Acknowledge that your health practitioner and Petersham Family Medical Centre will collect such information (including any personal or sensitive information), for the purposes of providing you with health services or enabling any related communications; and
Consent*
Consent to Petersham Family Medical Centre’s Terms & Conditions, and to Petersham Family Medical Centre handling your personal and sensitive information in accordance with its Privacy Policy.*

To complete this form you may need:
- Medicare card
- Pension/Healthcare/Concession card
Please make sure you have any relevant items ready before you begin.

To protect your personal information this form will clear and reset after 4 minutes of inactivity.

All fields marked with an asterisk (*) are required.

Personal Details
Title
First name*
Last name*
Preferred name
Gender*
- Female
- Male
Date of birth*

DD
MM
YYYY
Occupation
Street address*
Street address line 2
Suburb*
State*
Postcode*

Health Initiatives
In order to assist us with health initiatives and tailor care
Do you identify as Aboriginal or Torres Strait Islander?*
- Yes
- No
Please select what you identify as*
- Aboriginal
- Torres Strait Islander
- Aboriginal/Torres Strait Islander
What is your country of birth
Medical Information
IMPORTANT (Please read)

If you require an ePrescription or vaccine exemption certificate, your doctor will need your Medicare or DVA card details or IHI (Individual Health Identifier) number to offer you any of these services. Medicare issues IHIs. If you already have a Medicare card or a DVA card, you also have an IHI- Medicare has automatically allocated one to you.
Medicare card
Do you have a medicare card?*
- Yes
- No
Medicare card - Number*
Medicare card – Position on card*
Medicare card – Expiry date*

DD
MM
YYYY
DVA card
Do you have a DVA card?
- Yes
- No
DVA Card - Type*
- Gold
- White
DVA Card – Expiry date*

DD
MM
YYYY

Emergency Contact Information
We collect this information in case of an emergency
Next of kin
Next of kin – First name*
Next of kin – Last name*
Next of kin – Relationship*
Next of kin – Contact number*
Emergency contact
Same as Next of kin
- Same as Next of kin
Emergency contact – First name*
Emergency contact – Last name*
Emergency contact – Relationship*
Emergency contact – Contact number*

Your Health History
Do you have any allergies or are you sensitive to drugs or dressings*
- Yes
- No
Please list*

Social Activities
Do you smoke?*
- No
- Yes
- Ex Smoker
How frequently do you smoke? (eg 2 cigarettes daily/weekly)*
If you’re an ex smoker, can you please provide the approximate date that you ceased smoking?*

DD
MM
YYYY
Do you drink alcohol?*
- No
- Yes
How often do you have a drink containing alcohol?*
How many standard drinks containing alcohol do you have on a typical day?*
How often do you have six or more drinks in one occasion?*
Are you concerned about drinking?*
- Yes
- No

Regarding Pathology/Radiology Investigations

For GP consultations, if your doctor refers you to a pathology and/or radiology service provider for blood tests and/or X-rays, CT or other scans, you will need to make a follow-up appointment for your doctor to evaluate and discuss the results/reports with you.

Also, please note that, because our doctors consult patients nationwide, some pathology or radiology service providers may not yet be linked to our practice management software to allow for automatic download of their test/scan results to our system. You will therefore need to personally follow up and ask your chosen pathology or radiology service provider to send any results of tests/scans etc to the requesting doctor at our practice, via the following:

FAX: 02 9568 4678
or
EMAIL: info@pfmc.net.au

Which service did you request at the time of your booking?
Which service did you request at the time of your booking?

IMPORTANT (Please read) -

If you requested any of the following services, please select carefully below and provide additional information to complete your booking. Otherwise, click the “NEXT” button below to proceed to complete this form –.
Which service do you require today?
- Quick Prescription Service
- Absence From Work Certificate
- COVID-19 Vaccine Exemption Certificate
- Appointment with a Psychologist
- Appointment with a Dietitian
- Appointment with a Physiotherapist
- Appointment with a Podiatrist
Select Appointment Category
- Psychologist Appt- New Patient (60min In -Clinic)
- Psychologist Appt (30min In-Clinic)
- Telehealth Psychologist Appt-New Patient (60 mins)
- Telehealth Psychologist Appt (30 mins)
- Psychologist Appt-New Patient (60min In -Clinic) with Concession Card
- Psychologist Appt (30mins In -Clinic) with Concession Card
- Telehealth Psychologist Appt-New Patient (60 mins) with Concession Card
- Telehealth Psychologist Appt (30 mins) with Concession Card
Select Appointment Category
- Dietitian Appt-New Patient (60min In -Clinic)
- Dietitian Appt (30min In -Clinic)
- Telehealth Dietitian Appt-New Patient (60 mins)
- Telehealth Dietitian Appt (30 mins)
- Dietitian Appt-New Patient (60min In -Clinic) with Concession Card
- Dietitian Appt (30min In -Clinic) with Concession Card
- Telehealth Dietitian Appt-New Patient (60 mins) with Concession Card
- Telehealth Dietitian Appt (30 mins) with Concession Card
Select Appointment Category
- Physiotherapist Appt-New Patient (60min In -Clinic)
- Physiotherapist Appt (30min In -Clinic)
- Telehealth Physiotherapist Appt-New Patient (60 mins)
- Telehealth Physiotherapist Appt (30 mins)
- Physiotherapist Appt-New Patient (60min In -Clinic) with Concession Card
- Physiotherapist Appt (30min In -Clinic) with Concession Card
- Telehealth Physiotherapist Appt-New Patient (60 mins) with Concession Card
- Telehealth Physiotherapist Appt (30 mins) with Concession Card
Select Appointment Category
- Podiatrist Appt-New Patient (60min In -Clinic)
- Podiatrist Appt (30min In -Clinic)
- Telehealth Podiatrist Appt-New Patient (60 mins)
- Telehealth Podiatrist Appt (30 mins)
- Podiatrist Appt-New Patient (60min In -Clinic) with Concession Card
- Podiatrist Appt (30min In -Clinic) with Concession Card
- Telehealth Podiatrist Appt-New Patient (60 mins) with Concession Card
- Telehealth Podiatrist Appt (30 mins) with Concession Card

Absence From Work Certificate
Please answer the questions below:
01. Are you unwell and too ill to attend work today?*
- Yes
- No
02. Have you had symptoms or an illness like this before?*
- Yes
- No
03. Do you intend to see a doctor if your symptoms are not improving by tomorrow?*
- Yes
- No
04. Are you experiencing any of the following symptoms: severe pain in the head or abdomen, fever above 39 degrees, repeated vomiting or vision disturbances?*
- Yes
- No
05. Do you suffer any chronic medical conditions?*
- Yes
- No
One of our Australian registered doctors will review your answers and may contact you directly should further information be required. If your request is approved, we will email your Absence From Work Certificate directly to you.

Medicine Category:

Sub-category: NA

Sub- sub category: NA

Selected Medicine:

Requested Medication Details:

Answers to the questions asked-

Select Medicine Category

Select a sub-category

Select a sub- sub category

Select Your Medication

Requested Medicine

Please answer the questions below:

Preferred Pharmacy
In the event that a doctor prescribes a prescription to a patient, that prescription will be sent by the doctor electronically either to the patient as an ePrescription or a registered Australian pharmacy of the patient’s choice, or if the patient does not specify a pharmacy, it will be sent to an Australian accredited pharmacy situated in an area close to the patient’s home. The pharmacy will then dispense the medication.
Pharmacy name
Pharmacy address
Pharmacy contact phone
Pharmacy contact email

Regarding Medicare Rebate
You might be eligible for a $89.65 Medicare Rebate if you have a valid Medicare card and referral (Care Plan) from a GP through a Mental Health Care Plan (MHCP).

If you wish the $89.65 Medicare rebate to be paid directly into your bank account following the consultation, please provide us with the following details:
You might be eligible for a 63.55 Medicare Rebate if you have a valid Medicare card and referral (Care Plan) from a GP through a Mental Health Care Plan (MHCP).

If you wish the $63.55 Medicare rebate to be paid directly into your bank account following the consultation, please provide us with the following details:
Please upload below a copy of your referral (Care Plan) from a GP through a Mental Health Care Plan (MHCP):

(Files must be less than 2 MB. Allowed file types: pdf, png and jpg)
Attach File
Drop files here or

Accepted file types: pdf, jpg, png, jpeg.
If you have not already provided us with your Medicare card details,
please enter your valid Medicare card details below:
Medicare card - Number:
Medicare card – Position on card:
Medicare card – Expiry date:

DD
MM
YYYY
Have you already updated your bank account details with Medicare?
- Yes
- No
IMPORTANT

If you do not provide us with the above details and have not already updated your bank account details with Medicare, we cannot process payment of the Medicare rebate directly into your account. Instead, we can provide you with a receipt for the consultation, with which you can claim the rebate from Medicare directly yourself, provided you are eligible for the rebate.

Regarding Medicare Rebate
You might be eligible for a $56 Medicare Rebate if you have a valid Medicare card and referral (Care Plan) from a GP through a Chronic Disease Management Plan (CDMP).

If you wish the $56 Medicare rebate to be paid directly into your bank account following the consultation, please provide us with the following details:
You might be eligible for a $56 Medicare Rebate if you have a valid Medicare card and referral (Care Plan) from a GP through a Chronic Disease Management Plan (CDMP).

If you wish the $56 Medicare rebate to be paid directly into your bank account following the consultation, please provide us with the following details:
Please upload below a copy of your referral (Care Plan) from a GP through a Chronic Disease Management Plan (CDMP):

(Files must be less than 2 MB. Allowed file types: pdf, png and jpg)
Attach File
Drop files here or

Accepted file types: pdf, jpg, png, jpeg.
If you have not already provided us with your Medicare card details,
please enter your valid Medicare card details below:
Medicare card - Number:
Medicare card – Position on card:
Medicare card – Expiry date:

DD
MM
YYYY
Have you already updated your bank account details with Medicare?
- Yes
- No
IMPORTANT

If you do not provide us with the above details and have not already updated your bank account details with Medicare, we cannot process payment of the Medicare rebate directly into your account. Instead, we can provide you with a receipt for the consultation, with which you can claim the rebate from Medicare directly yourself, provided you are eligible for the rebate.

What is the official date you tested positive to COVID-19 (Coronavirus) ?*
Date Format: DD slash MM slash YYYY
Please upload below a copy of your COVID-19 (PCR test or RAT test) result :

(Files must be less than 2 MB. Allowed file types: pdf, png and jpg)
Attach File*
Drop files here or

Accepted file types: pdf, jpg, png, jpeg.
Also, if applicable – please upload below a copy of evidence of the registration of your result with relevant state health department :
Attach File
Drop files here or

Accepted file types: pdf, jpg, png, jpeg.
Please note:

The maximum period of exemption following a confirmed SARS-CoV-2 infection is 6 months from the date of diagnosis.

(Must be confirmed with PCR test OR RAT test that has been registered with relevant state health department)

The Australian Immunisation Register is linked to your Medicare records. You can access your exemption either through your my.gov.au account or by downloading the Medicare app to your phone - navigate to the section marked “Proof of vaccinations”.

The ATAGI advice is not that it’s recommended to withhold vaccination following a SARS-CoV-2 infection.

ATAGI strongly recommends that all eligible Australians receive their full course of vaccination.

The temporary vaccine exemption following infection is simply a recognition that there will be a period of natural immunity following infection.

Source
How Did You Hear About Us?
Please specify
Communication
I consent to receive SMS reminders, messages and emails*
- Yes
- No

Privacy and Terms
Please sign (using your finger or computer mouse) or place your electronic signature in the box below to confirm that you have read and agree to our “Terms & Conditions” and “Privacy Policy” and that all the information you have provided us in this form is true and correct to the best of your knowledge and belief.
Signature*

Bulk Billing Criteria for GP Services

For Telehealth/Phone consults:

You are eligible for a bulk billed Telehealth/Phone consult with one of the above doctors provided: 1) you have a valid Medicare card, and 2) one or more of the following circumstances apply to you–

You require a Telehealth/Phone consult (not longer than 10 mins) AND you have visited Petersham Family Medical Centre in person for at least one face-to-face service from any health professional at the practice in the previous 12 months. (If you are unsure, please call (02) 95608207 or email the practice and we will confirm this attendance).
You need an urgent after-hours telehealth consult during unsociable afterhours period – 11 pm through to 8 am weekdays, hours outside of 8 am and 12 noon Saturdays and all day Sundays and public holidays.
You need a consult to access mental health services.
You are homeless because you are going through an extreme form of poverty due to the inadequacy of income, health care supports and social supports.
The service is for a child under the age of 12 months.
You are a patient of a medical practitioner at an Aboriginal Medical Service or an Aboriginal Community Controlled Health Service.
You need a consult relating to blood borne viruses, sexual or reproductive health.
People isolating because of a COVID-related State or Territory public health order, or in COVID-19 quarantine because of a State or Territory public health order.
People affected by natural disaster, defined as living in a local government area declared a natural disaster by a State or Territory government.

For Face-to-Face consults:

For face-to-face consults, the following categories of patients are bulk billed –

I am a valid Medicare Card holder who requires a face-to-face consult.

Bulk Billed & WorkCover Consultations

Click on this link – Bulk Billing Criteria for GP Services to check your eligibility before requesting a bulk billed appointment by email. If you are eligible and you DO wish to request a bulk billed appointment by email, please click on the link below –

Request a Bulk Billed Appointment

Click on this link – Eligibility Criteria for WorkCover Consults to check your eligibility before requesting a WorkCover consultation by email. If you are eligible and you DO wish to request a WorkCover consultation by email, please click on the link below.

Request a WorkCover Consult

Eligibility Criteria for Workcover Consults

If you wish to request a WorkCover consultation by email, you will need to provide us with ALL of the following information:

Employer details –

Company or Business Name
Phone
Email

Insurer details –

Company Name
Claim number
Case manager’s full name
Phone
Email
A copy of any relevant evidence of any correspondence (notices, emails, letters, etc) between you and your insurer that clearly shows that your claim is covered by your insurer and is valid for future consults with our doctors.

IMPORTANT

If you cannot provide us with the details listed above, and attach evidence of your eligibility, we unfortunately are not able to give you an appointment for a WorkCover consult with one of our WorkCover doctors unless you pre-pay for the consult.

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Pre-appointment Client Form

Step 1 of 18

Personal Details

Health Initiatives

Medical Information

IMPORTANT (Please read)

Medicare card

DVA card

Emergency Contact Information

Next of kin

Emergency contact

Your Health History

Social Activities

Regarding Pathology/Radiology Investigations

Which service did you request at the time of your booking?

Which service did you request at the time of your booking?

IMPORTANT (Please read) -

Absence From Work Certificate

Preferred Pharmacy

Regarding Medicare Rebate

Please upload below a copy of your referral (Care Plan) from a GP through a Mental Health Care Plan (MHCP):

If you have not already provided us with your Medicare card details,
please enter your valid Medicare card details below:

Regarding Medicare Rebate

Please upload below a copy of your referral (Care Plan) from a GP through a Chronic Disease Management Plan (CDMP):

If you have not already provided us with your Medicare card details,
please enter your valid Medicare card details below:

Please upload below a copy of your COVID-19 (PCR test or RAT test) result :

Also, if applicable – please upload below a copy of evidence of the registration of your result with relevant state health department :

Source

Communication

Privacy and Terms

Pre-appointment Client Form

Step 1 of 18

Personal Details

Health Initiatives

Medical Information

IMPORTANT (Please read)

Medicare card

DVA card

Emergency Contact Information

Next of kin

Emergency contact

Your Health History

Social Activities

Regarding Pathology/Radiology Investigations

Which service did you request at the time of your booking?

Which service did you request at the time of your booking?

IMPORTANT (Please read) -

Absence From Work Certificate

Preferred Pharmacy

Regarding Medicare Rebate

Please upload below a copy of your referral (Care Plan) from a GP through a Mental Health Care Plan (MHCP):

If you have not already provided us with your Medicare card details, please enter your valid Medicare card details below:

Regarding Medicare Rebate

Please upload below a copy of your referral (Care Plan) from a GP through a Chronic Disease Management Plan (CDMP):

If you have not already provided us with your Medicare card details, please enter your valid Medicare card details below:

Please upload below a copy of your COVID-19 (PCR test or RAT test) result :

Also, if applicable – please upload below a copy of evidence of the registration of your result with relevant state health department :

Source

Communication

Privacy and Terms

If you have not already provided us with your Medicare card details,
please enter your valid Medicare card details below:

If you have not already provided us with your Medicare card details,
please enter your valid Medicare card details below: