Welcome to Ranges Medical in New Gisborne. We are committed to providing our patients with the best care. Please don’t hesitate to ask us if you have any questions or concerns. Please print clearly- All sections must be completed.

First Title: Dr Prof Mr Mrs Miss Ms Other Important! name must be as it appears on yourMedicare or Insurance card
FAMILY NAME: Given name:
I prefer to be called(name if different to given name):
Date of birth: ___/_____/______Gender : Male □ / Female □ / Self nominated: ______
Cultural background: Non-Indigenous □ Aboriginal □ Aboriginal and Torres Strait Islander □ Torres Strait Islander □
Other: (please state)______
MEDICARE NUMBER: /
Ref no.
This is the number next to your name on the card / Expiry date:
Pension / DVA number: Card type: Expiry date:
HCCnumber : Expiry date:
OSHC number (overseas students only) : Expiry date:
Do you have amyHealth record? Yes □ No □ If No:I agree to have a myHealth record Yes □ No □
Address
Number and street:______Suburb : ______State:______Postcode______
Postal address (If different):______
At least one number must be nominated
Contact number (Home): ______
Contact number ( Mobile): ______
Email: ______/ RM uses a variety of electronic communications like SMS/Email for appointmentreminders (SMS only), health reminders, recalls and health information.
PLEASE TICK YOUR PREFERRENCE(S)FOR COMMUNICATION
[ ] EMAIL [ ] SMS [ ] DO NOT CONTACT BY EMAIL/SMS
We do NOTprovide results or other medical correspondence via email/SMS.
Marital status: No of children & ages:
Country of birth : Occupation:

Emergency contact person:

Name: Contact number:
Relationship to you:

MEDICAL HISTORY Please briefly complete this section to the best of your knowledge – this will be discussed further with your GP.

Medical history:______

Surgical history:______

Current medications – list all including natural / herbal remedies / Allergies
Nil known

Have any of your family members (mother, father, grandparents, siblings, children) had the following?

***If you ticked yes to any of these, please write next to it who was affected

Diabetes Mental Illness

Asthma Cancer / Type______

Heart Disease Other (Please Specify) ______

Ladies: When did you have your last PAP smear? ______

Social history:

Never smoked Smoker No. per day______OR ceased smoking -Date______

Average Number of days you drink per week: ______Average number of drinks per day and type ______

TERMS AND CONDITIONS:May 2018

Dear Patients, please note the following policies for this practice;

*** We have ZERO TOLERANCE of abuse of our staff either in person or on the phone. You will be asked to leave the practice***

Appointments: Our reception staff will ask you at the time of booking which doctor you would prefer to see and discuss the length of appointment you require. Please note a ‘standard appointment’ is 15 minuteslong and allows for the discussion of one to two simple issues. If you require completion of forms, have complex or multipleissues to discuss or need a procedure of any kind, including a pap smear, then please ask for a ‘double appointment’. This ensures there is minimal delay for other patients who are waiting. Advising our reception staff will ensure they book the most efficient and cost effective appointment for you. Please note not all of our Doctors undertake all procedures.

After hours care: For allurgent medical care after hours phone the After-hours GP help line: 1800 022 222.

Privacy statement and consent to release relevant health information: We require that you to provide us with your personal details and a full medical history so that our Doctors can properly assess, diagnose, treat and respond to your health care needs. We do not share this information without your consent in accordance with the National Privacy Principles (NPP) and the Privacy Act. Information regarding your medical records will only be released following a request in writingand with relevant approvals. For more information on our Privacy Policy, refer to Ranges Medical’s notice board & website.

Practice Fees: We are a private billing practice.All consultations are payable on the day. The practice has claim facilities allowing patients to pay and then claim the Medicare rebate on site. When making your appointment please enquire with the receptionist as to the fee applicable. We BULK BILL children under 16,DVA and aged/disability pensioners, and there is a concession fee for patients holding ahealth care card including Commonwealth Seniors’ Health Card. Cards must be shown at the time of payment.

Phone calls / emails: As courtesy to the patient seeing a GP, as well as privacy, our Doctors do not accept calls during consultation times. Please leave a message with the reception staff and they will pass the message onto the Doctor who will return your call if appropriate. Our practicedoes not use email to communicate with patients as the privacy/security of emails cannot be guaranteed.

Scripts and referrals to specialists without appointments: To maintain quality healthcare, a consultation with the doctor is generally required to determine the appropriateness of each request for a referral or prescription, even if it is an ongoing concern.

Please note: it is illegal for Doctors to backdate referralsto specialists and medical certificates. Please do not make such a request.

**Results: In the interest of good healthcare, generally patients will be asked to make an appointment to discuss results, though on occasion a Doctor may make alternative arrangements with you. Our reception staff are NOT able to provide result over the phone.

Reports/Paperwork: If you require reports or any kind of paperwork completed you will need to make a double appointment with the Doctor and attend in person. We will not complete any forms, including driver’s licence forms unless you attend a consultation. These consultations may not be subject to a Medicare rebate - check with reception. Additional administration costs may be incurred for printing, faxing or postage as required.

Late cancellations / No shows for booked appointments: We would appreciate that you give as much notice as possible if you are unable to attend your appointment (minimum 4 hrs). Failure to attend appointments causes inconvenience for the Doctors and patients who missout on appointments.

Feedback: This Practice prides itself on providing high quality healthcare. If you have any questions, concerns or complaints please speak or team or you can place a comment in our suggestion box. You can contact the Practice Manager in person, by phone or in writing with the details above. Alternatively you can contact Health Quality and Complaints Commission at or phone on 1300 582 113.

Health Promotion and Preventative Care: Ranges Medical operates a patient reminder system and preventative medicine program for follow up and education regarding important medical issues. Please notify staff if you do not wish to be contacted via SMS and/or email. The practise website provides information about our services at

Translation services: Please notify our receptionists PRIOR to the appointment if you require translation/ National Relay Services (hearing / speech impaired) so that this can be arranged. Some of our Doctors speak several languages so please discuss any requirements when you book.

I have read and understood the terms and conditions of Ranges Medical

Your Signature: ______Date: ______

Parent/Guardian

You can book online at

Please tell us how you found out about Ranges Medical? *** please tick all that apply:

Driving by Family / Friends

Local newsletter (e.g. Gisb Gazette, Woodend Star) Professional referral

Facebook Referred by (Please specify) ______

Website IGA TV screen

Flier in the mail/PO Box