Marina 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

Patient Portal

The portal gives you access to appointment booking, easy messaging with the clinic, ability to request prescriptions, check your results, see what immunisations are on record and what you might need, any recalls in place for health screening and much more. You can access the portal by your web browser or on a free App on your iOS or Android device.

If you have children under 16yrs you will be able to book appointments for them using the portal.

Please note: To register you must be over 16 and not share an email address with anyone.

Why this clinic

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

Signature

Terms of trade

In line with normal business practices, payment is expected at the time of doctor consultation. Any cost incurred in recovering any outstanding balance will be payable by you, including all legal charges. If the account remains unpaid the patient consents to personal details relevant to the actual account being passed on to the recovery agent.

ALL THE INFORMATION GIVEN IS TRUE TO MY KNOWLEDGE AND I ACCEPT THE TERMS OF PAYMENT

⚠️ 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.