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Recruitment & Employment
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New Patients

Home
About Us
Patient Services
GP Services
Specialty Services
Recruitment & Employment
New Patient Registration
Contact Us
New Patients

New Patients

Home » New Patients

1 COVID-19

2 Your Clinic

3 Contact Information

4 Medicare & Benefits

5 Next of Kin / Emergency Contacts

6 ADF

7 Medical History

8 Consent

9 General Questions

10 Signature & Approval

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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Please select your nearest location
Clinic

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Your Contact Information
Prefix*
Preferred*
First Name*
Last Name
Gender*
Date of Birth*
Date Format: DD slash MM slash YYYY
Your Phone Number (Primary)*
Secondary Phone Number
Email
Occupation*
Country of Birth*
Ethnicity*
Address*
Street Address City State / Province / Region ZIP / Postal Code 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

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Medicare
Medicare & Reference No.
Medicare Number*
Reference Number*
Month*
Year*
Benefits
Pension / DVA / Health Care Card
Card Number
Expiry Date
Date Format: DD slash MM slash YYYY

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Next of Kin
Contact Details
Relationship to Patient*
Name*
Date of Birth*
Date Format: DD slash MM slash YYYY
Phone Primary*
Phone Secondary
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Emergency Contact Details
Relationship to Patient*
Name*
Date of Birth*
Date Format: DD slash MM slash YYYY
Phone Primary*
Phone Secondary
Address*
Street Address City State / Province / Region ZIP / Postal Code Country

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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

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Medical History
An overall check-up*
Have you recently had an overall check-up?
- Yes, Recently
- No
Date of last check up
Date Format: DD slash MM slash YYYY
Pap Smear*
- Yes
- No
- Not Sure
Have you had a Pap Smear recently?
Date of last Pap Smear
Date Format: DD slash MM slash YYYY
Breast Check*
- Yes
- No
- Not Sure
Have you had a Breast Check recently?
Date of last Breast Check
Date Format: 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?*
Immunisations
- Influenza
- Pneumococcal pneumonia
Date of last Influenza Immunisation
Date Format: MM slash DD slash YYYY
Date of last Pneumococcal pneumonia Immunisation
Date Format: MM slash DD slash YYYY

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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

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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

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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
This field is for validation purposes and should be left unchanged.

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Helpful Links

Clinic Finder/Book Online

New Patient Registration

Become a Supplier

Visiting Specialists / Room Hire

Australian General Practice Accreditation has independently recognised that this practice is committed to delivering safe and high-quality health care to our patients by complying with the Royal Australian College of General Practitioners (RACGP) Standards for general practices.

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All Clinics are predominantly 100% Bulk Billing

Contact Us – Head Office

Level 1, 87-89 Langtree Avenue, Mildura, Victoria, 3500 View on Map

Email Us
+61 3 5022 5800
+61 3 5022 5899

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