Patient Registration | Petersham Family Medical Centre

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.*

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*

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

Preferred Pharmacy (Optional)
If your doctor prescribes you a prescription and you would like the doctor send that prescription electronically to a registered Australian pharmacy of your choice where you would like a pharmacist to dispense the medication, please enter your preferred pharmacy details below. If you do not specify a pharmacy, it will be sent to an accredited pharmacy near you. A hard copy will also be sent to this pharmacist and to your postal address.
Pharmacy name
Pharmacy address
Pharmacy contact phone
Pharmacy contact email

Privacy and Terms
We are committed to protecting the confidentiality of your personal information and health records. In submitting this form, you;
1. acknowledge that we, and our service providers, will collect your personal and health information to enable us to provide you with our health services and any related communications (for example, to manage your appointment bookings); and
2. consent to our handling of your personal information in accordance with our Privacy Policy* or by asking us for a copy.
Do you agree to the terms & conditions?*
I agree.
Signature*
Card Payments
(Only required if you are not eligible for bulk billing)
Card Payments

(Only required if you are not eligible for bulk billing)

We accept
Please call the practice on (02) 9560 8207 before your appointment with your credit card details so that Petersham Family Medical Centre can process all fees and charges relating to the consultation following the conclusion of the consultation. Please note, for all patients who are not eligible for bulk billing, your doctor will not be available at the appointment time if you do not complete this process before the appointment.

Personal Details