Patient Registration & Consent Form

Complete your details below so our team can prepare your medical record before your visit. It only takes a few minutes.

Part 1 - Personal Data

Tell us who you are and how to reach you

Today's date

Title

Surname

First Name

Date of Birth

Parent/Guardian Name

Relationship

Guardian Relationship

Gender

Male Female

Address

Phone

How Did Your Hear About us?

Next of Kin

Relationship

Next of Kin Address

Part 2 - Health History

Help our clinicians prepare for your visit

Allergies

Medical History

Surgical History

Current Medications

Preferred Pharmacy Name

City

County

Reason for Appointment

Part 3 - Patient Consent

Please review and confirm each item below

Part 3 - Patient Consent

Please review and confirm each item below

I have read a copy of the Practice Privacy Statement.

I consent to The Walk In Clinic holding my data on record for the purposes of providing medical services.

I consent to The Walk In Clinic sending text messages to my mobile phone.

I consent to The Walk In Clinic holding a record of my PPS number.

If guardian, do you have legal authority to give consent on the patient's behalf?

Full Name (Signature)

Date

Call us for any question

Email

Patient Registration & Consent Form

Part 1 - Personal Data

Part 2 - Health History

Part 3 - Patient Consent

Part 3 - Patient Consent

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