Update Patient Details

ID Number*
Please enter a value between 0 and 999999999999.
Please insert the ID number, you have been provided - you will find this within your appointment letter
First name*
Middle name
Last name*
Preferred name
Date of birth*
Sex*
- Male
- Female
- Other
Ethnicity*
- Australian, non indigenous
- Aboriginal but not Torres Strait Islander
- Torres Strait Islander but not Aboriginal
- Both Aboriginal and Torres Strait Islander
- Other
Address*
Street Address Address Line 2 Suburb/City State Postcode Country

This is your home address and must be provided for claiming through Medicare
My postal address is...
- the same as my residential address
- different from my residential address
Postal Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mobile Phone Number*
Home Phone Number
Work Phone Number
Email*
Do you consent to SMS reminders*
- Yes
- No
Medicare number*
What is the number next to your name*
Enter your Medicare card expiry date*
Do you have any of the following concession cards:
- Health Care Card
- Pension Card
- Seniors Card
Enter your concession card number*
Enter your concession card expiry date*
Do you have a Department of Veteran Affairs Card and if so what colour?
- No
- Gold
- White
- Lilac
- Orange
DVA card number
Private health fund name (leave blank if not insured)
Private health fund member number
Next of kin*
First Last
Next of kin address
Street Address Address Line 2 Suburb/City State Postcode Country
Next of kin phone number*
Next of kin phone number alternate
Relationship with next of kin*
Emergency contact same as next of kin
- Yes
- No, other - add details below
Emergency contact person*
First Last
Emergency contact person address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency person phone number*
Emergency person phone number alternate
Relationship with emergency person*
Blood group
- A
- B
- AB
- O
- Unknown
Blood group Rh
- Positive
- Negative
List any medications, foods or products you are allergic to (if none known please enter "Nil Known")*
Are your allergic reactions...
- Mild
- Moderate
- Severe
Family history- tick which statements apply*
- I don't know my family history (eg adopted)
- I have no significant family history
- My mother is still alive
- My mother has passed away
- My father is still alive
- My father has passed away
For your mother, please choose any diagnosed conditions?
For your father, please choose any diagnosed conditions?
For your brother, please choose any diagnosed conditions?
For your sister, please choose any diagnosed conditions?
What age was your mother when she passed away and what did she die from?
What age was your father when he passed away and what did he die from?
Marital status
- Single
- Married
- De facto
- Separated
- Divorced
- Widowed
Are you an Elite Athlete?
- Yes
- No
Accommodation
- Own home
- Relative's home
- Nursing home/supported care
- Rental home
Who do you live with
- Alone
- Spouse
- Relative
- Friend
Do any of the following statements apply
- I have a carer who is listed as my next of kin above
- I have a carer who is listed as my emergency contact above
- I have a carer who is not listed above
- I am a carer
Carer name
First Last
Carer address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Carer phone number
Carer phone number alternate
Relationship with carer
Current occupation*
Current work status*
- Employed
- Unemployed
- Retired by choice
- Medically retired
- Medically unfit for work
Smoking History*
- Non smoker
- Smoker
- Ex Smoker
Smoking details
- Cigarettes
- Pipe
- Cigars
Number of cigarettes smoked per day*
Please enter a value between 1 and 100.
Quantity per day
- <1
- 1-9
- 10-19
- 20-39
- 40+
Year started
Please enter a value between 1900 and 2100.
Year stopped
Please enter a value between 1900 and 2100.
Alcohol consumption*
- Non Drinker
- Current Alcohol Intake
- Past Alcohol Intake
Past Alcohol Intake
- Nil
- Occasional
- Moderate
- Heavy
Number of days per week you drink*
Number of standard drinks on days you have alcohol*
Digital Health Folder - Halaxy: a secure online health portal. This will allow Ballina Health Centre to give you ongoing access to your pathology and imaging results, nutrition plans, in-house test results, research papers and pathology request forms. Please select "yes" if you wish to have your health portal created.
Online Access to Supplements - Vital.ly: This will allow Ballina Health Centre to give you access to order your prescribed supplements online. Please select "yes" if you wish to have your vital.ly account created.
Clinic Policies - Reminder System*
- Our practice is committed to preventative healthcare. We may issue you with a reminder letter from time to time offering you preventative heatlh services appropriate to your care. We do also offer SMS reminders for your booked appointments. If you do not wish to be part of these systems please let us know at reception.
Please tick box to confirm you have read and understand this policy
Clinic Policies - Pathology testing*
- As a lifestyle and prevention based clinic, we order a combination of Medicare-funded and private investigations. Medicare has specific guidelines for GP's to follow when ordering Medicare-funded tests, these must be clinically relevant and written within a consultation. Private testing may be suggested to optimise your treatment program and will incur out of pocket expenses if you choose to proceed. Investigations suggested by external practitioners that are not considered clinically relevant by Medicare or required outside of a medical consultation will need to be ordered privately.
Please tick box to confirm you have read and understand this policy
Clinic Policies - Obtaining Test Results*
- If you have had tests performed and Dr Hayter should consider it necessary to discuss them with you, one of our team members will contact you by phone to set up a time to see one of our practitioners. We will only contact you if it is necessary for the Doctor to see you.
Please tick box to confirm you have read and understand this policy
Clinic Policies - Cancellations*
- We request that cancellation of 1st and all long appointments be made at least 5 business days prior to the consultation date and at least 24 business hours before the consultation date for all other appointment types. This will enable us to allocate your appointment to a waiting client. Failure to cancel you appointment may attract a fee equal to 50% of the consultation fee.
Please tick box to confirm you have read and understand this policy
Clinic Policies - Payment*
- Payment: Please refer to the schedule of fees for details on different services and treatments. No accounts are offered. Payment is due strictly at the time of consultation. Facilities for cash, credit cards and EFTPOS are available. Cheques are not accepted. Telephone and Skype consultations are to be paid at the time of consultation via credit card. Please note that these consultations do not usually attract a Medicare rebate (due to COVID 19, until September 2020, a Medicare rebate is available). Supplements must be paid for in full prior to dispatch and cannot be returned or exchanged. No accounts are offered.
Please tick box to confirm you have read and understand this policy

Update Patient Details Form