Botany Junction Medical

New Patient Questionnaire

Language

This form is required to complete your enrolment

Measurements

Insurance and pharmacy

Medical history

Do you have, or have you had any of the following medical problems? Or is there a family history of the following? (Please tick those that apply)
SelfFamily
SelfFamily

Lifestyle

Smoking

These questions are asked on the enrolment form, so they are not repeated here.

Email and Mobile Phone communications consent

I agree to the following terms and conditions when consenting to email/cellphone text communication with the staff at this practice.

The email address/cell phone number I have provided is my own and therefore only I have access to my messages. Where the email address/cell phone number is shared, I give consent for messages sent from this practice to be potentially shared by others who have access to my email account/mobile phone.

It is my responsibility to maintain the privacy of any emails/texts sent from this practice to my email address/mobile phone.

I give consent to send me emails/texts. This includes and is not limited to laboratory and radiology results, reminders for screening examinations/investigations, appointment reminders, invoices, statements and newsletters.

It is my responsibility to inform the practice if I change my email address/mobile phone number.

Please note the clinic has a: Text messaging “no reply response”

Tick just ONE

Why this clinic

Why did you choose to transfer to our clinic? Please tick all that apply

Signature

ALL THE INFORMATION GIVEN IS TRUE TO MY KNOWLEDGE

⚠️ The capture ends at the signature and date. Submit and Cancel are the enrolment form’s own buttons, placed here so the page can be finished — their real wording, placement and behaviour are unverified.