The Digestive Health Centre

Thank you for choosing to complete your patient registration details via our Patient Portal.
This form will take approximately 20 minutes to complete online and is an essential part of us preparing for your admission.

Please Note:
Your information will get sent directly through to our medical records and will not be stored anywhere else.
If at any time you are interrupted, please ensure you complete the mandatory (*) fields, and click on the SUBMIT button at the end, so we do not lose your information.
Personal Details
Title *
First Name *
Surname *
Middle Name
Preferred Name
DOB *
/ Day / Month Year
All sections where you type in an address in this form will be automatically populated by Google.
Address *
Sex *
Occupation
Country of Birth
State of Birth
Marital Status
Religion
Are you of Aboriginal/Torres Strait Island descent?

Yes No
Postal Address Is?

Same As Above Different

IF Your Postal Address is a PO Box please enter the details here, else, use the address option below

	Tick Applicable
TB
Hepatitis
Jaundice
Exposure to AIDS virus
MRSA
VRE
Norovirus
Clostridium Difficile
Risk of Creutzfeldt-Jakob Disease?
CRE
Other

	Tick Applicable
Intellectual
Physical

	Tick Applicable
Hearing loss requiring aides?
Sight loss requiring aides?

Consent
We require your consent to enable us to handle personal information about you. Please read our privacy policy carefully, and tick the box where indicated below. If you have any concerns or queries about this, feel free to ask us for a further explanation. I have had the opportunity to read this centre’s privacy policy and understand the reasons why my information must be collected. I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me. I understand that my healthcare is a partnership between me and the health professionals at The Digestive Health Centre and will take reasonable steps to ensure that I provide up-to-date contact information both now and in the future to enable The Digestive Health Centre to contact me for follow-up purposes.

I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances. I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained. I consent to the handling of my information by this centre today and in future visits for the purposes set out in the privacy policy, subject to any limitations on access or disclosure of which I may notify this centre.
*

I Agree To The Terms Above
Should be Empty:

Personal Details