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New Patients
1
COVID-19
2
Your Clinic
3
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4
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5
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6
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7
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8
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9
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10
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COVID-19
Do you have a fever, cough, sore throat or shortness of breath?
*
Yes
No
Have you travelled overseas in the 14 days before getting sick? Or had contact with someone diagnosed or suspected of having Corona virus in the 14 days before getting sick?
*
Yes
No
Please call Telehealth on 1800 020 080 to organise a consultation and for further medical advice. For further advice please visit our
Clinic Finder
and call our nearest centre. Please be aware that by meeting the above criteria patients must refrain from entering the clinic.
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Address
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Canada
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Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
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Denmark
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Nigeria
Niue
Norfolk Island
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Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
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Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
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Saint Helena
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Samoa
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Country
Translator Required?
*
Yes
No
Language
ATSI
Do you identify as being Aboriginal or Torres Strait Islander?
ATSI
*
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, Aboriginal & Torres Strait Islander
No
Medicare
Medicare & Reference No.
Medicare Number
*
Reference Number
*
Month
*
Year
*
Benefits
Pension / DVA / Health Care Card
Card Number
Expiry Date
DD slash MM slash YYYY
Next of Kin
Contact Details
Relationship to Patient
*
Name
*
Date of Birth
*
DD slash MM slash YYYY
Phone Primary
*
Phone Secondary
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Emergency Contact Details
Relationship to Patient
*
Name
*
Date of Birth
*
DD slash MM slash YYYY
Phone Primary
*
Phone Secondary
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
ADF Service
Current Status
*
Never Served
Current Australian Defence Force – Permanent Member
Current Australian Defence Force – Reserves
Past Australian Defence Force – Permanent OR Reserves
Unknown
Medical History
An overall check-up
*
Have you recently had an overall check-up?
Yes, Recently
No
Date of last check up
DD slash MM slash YYYY
Pap Smear
*
Yes
No
Not Sure
Have you had a Pap Smear recently?
Date of last Pap Smear
DD slash MM slash YYYY
Breast Check
*
Yes
No
Not Sure
Have you had a Breast Check recently?
Date of last Breast Check
DD slash MM slash YYYY
Your health history
*
Do you have or have you had a history of?
Operations
Asthma
Diabetes
Heart Disease
High Blood Pressure
Mental Illness
Cancer
Muscular/skeletal (arthritis/muscle/joint pain)
None of the above
Other
Additional Information
Current medications
*
Social History
*
Tobacco
Alcohol
Drug use
Other
None of the above
Additional Information
Blood Pressure: when was the last time your blood pressure was taken?
Are you 65 years or older?
*
Yes
No
Immunisations
Influenza
Pneumococcal pneumonia
Date of last Influenza Immunisation
MM slash DD slash YYYY
Date of last Pneumococcal pneumonia Immunisation
MM slash DD slash YYYY
Consent and Approval
Tristar Medical Group requires your consent to collect personal information about you. Please read this consent form carefully, tick the applicable boxes and sign where indicated below. Tristar Medical Group collects such information for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history to allow us to properly assess, diagnose, treat and advise on all your health care needs. Please place a tick in the following boxes if you give consent for this information to be used by Tristar Medical Group in the following ways:
I give my permission for my personal health information to be used for administrative purposes to assist in the running of Tristar Medical Group, including disclosure to others involved in my healthcare, such as treating doctors and specialists within and outside Tristar Medical Group. This may occur through referral to other Doctors, or for medical tests and in the reports or results returned to my doctor following referrals.
I give my permission for my personal health information to be used for administrative purposes to assist in the running of Tristar Medical Group, including disclosure to others involved in my healthcare, such as treating doctors and specialists within and outside Tristar Medical Group. This may occur through referral to other Doctors, or for medical tests and in the reports or results returned to my doctor following referrals.
*
Yes
No
I give my consent for disclosure for research and quality assurance activities to improve individual, community health care and Practice management. This may occur when Tristar Medical Group incorporates patient health records into de-identifiable patient information to transfer to a third party, normally used for quality improvement projects. De-identifiable patient information cannot be traced back to the individual.
I give my consent for disclosure for research and quality assurance activities to improve individual, community health care and Practice management. This may occur when Tristar Medical Group incorporates patient health records into de-identifiable patient information to transfer to a third party, normally used for quality improvement projects. De-identifiable patient information cannot be traced back to the individual.
*
Yes
No
I give my consent for my personal health records to be used for identifiable patient health information. This may occur when Tristar Medical Group participates in research activities on behalf of a university as part of professional development activities to be collected. Identifiable patient information can possibly be traced back to the individual.
I give my consent for my personal health records to be used for identifiable patient health information. This may occur when Tristar Medical Group participates in research activities on behalf of a university as part of professional development activities to be collected. Identifiable patient information can possibly be traced back to the individual.
*
Yes
No
I give my consent to the presence of a third party to be present during my consultation. This may include a Practice Nurse or medical student.
I give my consent to the presence of a third party to be present during my consultation. This may include a Practice Nurse or medical student.
*
Yes
No
I give my consent to be part of the Practice’s National, State and Territory recall and reminder systems.
I give my consent to be part of the Practice’s National, State and Territory recall and reminder systems.
*
Yes
No
General Questions & Information
How did you hear about Tristar?
*
Telephone Book
Internet
Online
Pages Yellow/White
Signage
Family Member
Word of Mouth
Other Please Specify
How did you hear about Tristar?
Will this clinic provide you with the majority of care over the next 12 months?
*
Yes
No
Are you visiting the area?
Yes
No
Signature
By signing and submitting this form you understand that Tristar Medical Group is authorised on your behalf to use relevant personal information and you are free to withdraw your consent at any one time by verbal or written notification.
*
Email
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