CHHN Workplace Services Employee Registration Form

Employee Registration and Consent Form

PERSONAL DETAILS

MrMrsMissMsDr

First Name

Last Name

Preferred Name

Date of Birth

Sex

Male Female Other/not provided

Pronouns

She/herhe/himthey/them other

Do you identify as?

AboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait IslanderNone of the Above

CONTACT DETAILS

Mobile Phone

Address

Postcode

MEDICARE

Do you use a different name in your medicare card?

YesNo

If you use Alias please write the Alias name & surname

Name as listed on Medicare Card

Medicare Card No.

Individual Reference Number (number listed next to name) )

Expiry

PENSION / HCC/DVA Card

Do you have an aged pension card, healthcare card or a DVA card

YesNo

Card Type

HCCPension

Card No.

Expiry(mm/yyyy)

DVA Card Type

GoldWhiteLilacOrangeBlue

DVA No.

EMPLOYER DETAILS

Employer

Which service are you attending?

On-Site Workplace Clinic Voucher service (vaccination voucher provided by employer)

HEALTH INFORMATION

Allergies *

Have you ever experiences an adverse reaction to vaccinations or pharmaceuticals in the past? *

Yes (please specify below)No

Details

Do you have any chronic health conditions or notable medical history (including current pregnancy)? *

Yes (please specify below)No

Details

CONSENT

I confirm that above information I have provided is true, complete and accurate. *

I consent to be bulk-billed for services received *

I consent to receive vaccination. I have been informed of relevant information regarding the vaccination I am recieving. I understand that following injection I will be required to wait 15 minutes before leaving. If I experience any side effects I will inform the Nurse or Doctor present. *

Patient/ Guardian Signature

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