CHHN New Patient/Client Form

PLEASE CALL US TO BOOK OR WITH ANY APPOINTMENT QUERIES BEFORE COMPLETING THIS FORM.

THIS FORM DOES NOT INCLUDE APPOINTMENT BOOKING AND WE DO NOT OFFER ONLINE BOOKING.

Please call us on 4329 0799 for all appointment enquiries and bookings. If you are unable to book via phone please send us an email (admin@chhn.com.au) and we will attempt to accomadate as best we can.

Thank you.

If this form is completed without a prior phone call to book an appointment or enquiry we cannot guarntee an appointment or availability with any provider.

Practitioner you are seeingPlease note: Dr Edward Clarke is no longer practicing at Raglan Street Clinic as of Oct 2025

Clinic Location

Raglan Street Clinic (Ballarat)CHHN Avoca CHHN Creswick

Please note not all providers/services are available at all locations. Please refer to website for more details Reception Staff will confirm location when booking appointments.

Purpose of attendance

Have you already booked an Appointment? *

Yes - please continue completing the form No - Please call to book first Ph. 43290799

Personal Details

Title

First Name *

Preferred Name

Last Name *

Date of Birth *

Sex assigned at birth

Gender Identity

Preferred Pronouns

CONTACT INFORMATION

Mobile Phone (Best Contact number)

Home Phone

Work Phone

Preferred method of contact

PhoneSMS/textEmail

Do you consent to receiving SMS reminders?

Yes No

Email

Address

Postcode

City / Suburb

State

Postal Address (if required)

EMERGENCY CONTACT

Name

Primary contact number

Relationship to you

NEXT OF KIN

Is the next of Kin same as your emergency (if yes, you do not need to fill this section)

YesNo

Next of Kin - Name

Best Contact Number

Relationship to you

PREVIOUS, CURRENT, REFERRING DOCTOR

Name

Practice

Any relevant documentation (referrals, care plans, records etc. if applicable)

Browse

MEDICARE

Do you use a different name in your Medicare Card?

YesNo

If you use Alias please write the Alias name & surname

Full Name (as listed on card)

Medicare Card number

Individual reference number

Expiry(mm/yyyy)

If you do not have a Medicare Card there will be an out of pocket fee required for any services. Invoices will be provided on request for Health/travel Insurance reimbursments etc.

PRIVATE HEALTH INSURANCE

Do you have private Medical insurance

YesNo

Provider

Membership number

Expiry(mm/yyyy)

PENSION / HCC/DVA Card

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

YesNo

Card Type

HCCPension

Card No.

Expiry(dd/mm/yyyy)

DVA No.

Expiry(dd/mm/yyyy)

CULTURAL IDENTITY

How do you identify from the following (Please select all that apply)

Other Cultural/Linguistic/Ethnic background

Country of Birth

Preferred Language

Interpreter required

Yes No

HEALTH INFORMATION

Any relevant health information (e.g Allergies, medications, health conditons, notable factors etc.)

If applicable please list relevant details for any of the following as well as any other relevant health information.

Notable health conditions or factors

Allergies

Medications

Notable family history

CONSENT AND AGREEMENT

Access the full privacy policy and the pdf version of our information consent form here

https://www.chhn.com.au/

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

I consent to the collection, storage and use of my information by this practice as in line with the privacy policy and confidentiality agreement *

Patient/ Guardian Signature

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