Patient Name
*
First Name
Last Name
Patient Middle Name/s
Patient Preferred Name
Patient Date of Birth
*
MM
DD
YYYY
Patient Sex at Birth
*
Male
Female
Other
Patient Gender and Pronouns
Patient Primary Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Is the patient's postal address the same as above?
Yes
No
Patient Email Address, if applicable
Patient Mobile Number, if applicable
Country
(###)
###
####
Patient Medicare Card Number
*
Patient Medicare Reference Number (ie: the number next to their name)
*
Patient Medicare Expiry Date (MM/YY)
*
Patient Indigenous Status
*
Aboriginal
Torres Strait Islander
Neither
Patient Cultural Background
Patient Current School
Patient Current Year Level
Patient Current Teacher/s
Do you have a copy of your child's GP referral?
*
Parent / Guardian's Full Name
*
First Name
Last Name
Relation to Patient
*
Mother
Father
Grandparent
Sibling
Carer
Aunt
Uncle
Other
Date of Birth
*
MM
DD
YYYY
Residential Address
*
Same as Patient
Different Address
Email Address
*
Mobile Number
*
Country
(###)
###
####
Home Phone
Country
(###)
###
####
Occupation
Primary Contact Medicare Card Number
*
Primary Contact Medicare Reference Number (ie: the number next to their name)
*
Primary Contact Medicare Expiry Date (MM/YY)
*
Parent / Guardian's Full Name
First Name
Last Name
Relation to Patient
Mother
Father
Grandparent
Sibling
Carer
Aunt
Uncle
Other
Date of Birth
MM
DD
YYYY
Residential Address
Same as Patient
Different Address
Email Address
Mobile Number
(###)
###
####
Home Phone
(###)
###
####
Occupation
Secondary Contact Medicare Card Number
Secondary Contact Medicare Reference Number (ie: the number next to their name)
Secondary Contact Medicare Expiry Date (MM/YY)
How many weeks gestation was your child born at?
What was your child's birth weight?
Delivery Method
Vaginal
Caesarean
Apgar Scores?
When did your child first sit up? (in months)
When did your child first crawl? (in months)
When did your child first walk? (in months)
When did your child speak their first word? (in months)
When did they last have their vision checked?
When did they last have their hearing checked?
Are your child's immunisations up to date?
Yes
No
Tell us something awesome about your child. What are their strengths?
What are your current concerns about your child?
*
Child's Medical History
*
Please details the patient's medical history (including during pregnancy).
Current Medications
*
Does your child have any formal diagnoses?
*
Yes
No
Family Medical History
Please detail relevant medical history in the family. For example: grandparents, parents, siblings, cousins, aunt/uncles with mental illness, heart disease, asthma, intellectual disabilities etc.
What prompted you to make an appointment with a paediatrician for your child?
What are you hoping to get out of your child's appointment?
Please list up to three points.
Are any third parties (ie: DFFH) involved in the care or custodianship of the patient?
*
Are there any Court Orders relating to the care or custodianship of the patient?
*
Eltham Paediatrics is committed to best practice in relation to the management of the information we collect. Our Privacy Policy has been developed in compliance with the Privacy Act 1988 (Cth). To provide the best health care to your child, Eltham Paediatrics requires your consent for the collection, recording and appropriate or necessary communication of relevant personal health information. By proceeding with the establishment of a file for your child, you have indicated your consent for any private health care information provided, obtained or recorded during your health care relationship with Eltham Paediatrics to be kept and managed in accordance with our Privacy Policy.
*
A copy of our Privacy Policy is available on our website. If you have any questions or concerns, please
do not hesitate to contact us on 03 9437 0552 or email hello@elthampaediatrics.com.au.
I understand my child must attend all appointments and that I am responsible for the payment of fees at the time of the appointment. I understand there will be an out-of-pocket expense for appointments and that it is my responsibility to have a valid GP referral for each visit. I understand the Medicare rebate can only be claimed if I have a valid referral and my child attends the appointment. I consent to the collection, recording and appropriate or necessary communication of relevant personal health information as outlined in Eltham Paediatrics’ Privacy Policy. I consent to being contacted via SMS. I assign my right to benefits for bulk-billed phone calls or appointments to the health professional who rendered the service, where applicable. I have had the opportunity to ask questions and clarify any concerns.
*
