7/195 Hampton Rd,South Fremantle,
WA 6161
Call us
(08) 6424 8397
Working Hours
Mon - Fri 8AM - 6PM
Sat-Sun 9AM - 1PM
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Patient Registration Form

Our Practice is committed to providing our patients with the best care. To do this it is essential that your details are kept up to date, please complete the following form if you require assistance our receptionist will be happy to oblige.

Mr | Mrs | Ms | Miss | Master | Dr | Other

Male | Female | Gender Neutral
Aboriginal | Torres Strait Islander | Both | None

Yes | No



Yes | No

I acknowledge that Mill Point Medical is a Private Billing Practice and that all accounts must be paid at the time of consultation.
I understand that Mill Point Medical Centre complies with the Privacy Act (1988) and as part of their Privacy Policy they are committed to protecting the privacy of individuals and their personal information. The purpose for collecting my personal information is to provide quality medical and health related services and associated account keeping. I understand that I have the rights to request access to my information except where access would be denied and that the staff and doctors at Mill Point Medical Centre make every effort to manage my information in accordance with the National Privacy Principles and keep my records accurate and up to date. I understand that I may withdraw my consent for Mill Point Medical Centre to use and disclose my personal information except when legal obligations must be met.

This practice uses a recall and reminder system to enable a systematic approach to health promotion and preventative care. My signature below indicates that I have read the above and consent to the following:

  • Mill Point Medical Centre collecting, using, storing and disposing of my personal information
  • The release of relevant personal information to other health professionals to allow quality medical care eg specialist and pathologist
  • Inclusion in a recall register to be advised of follow-up visits, medical updates and health information
  • The release of relevant personal information to my employer/prospective employer, their authorised representative and their insurer in the case of a work related consultation or service

I also consent to having blood removed for testing of communicable diseases, including Hepatitis & HIV, in the event of the exposure of a staff member to my blood or body fluids.

I take full responsibility for attending a follow-up appointment with my doctor to discuss all test results ordered by my doctor.




Medical History

Thank you for allowing us to take care of you today (and hopefully the future too). To assist us it would be very helpful if you could answer a few health questions.


1. Are you a smoker? Yes | No



Yes / No

2. Do you drink alcohol? Y / N Yes | No




3. Do you have any allergies, particularly to medicines but other triggers as well? Yes | No




4. Do you have a history of any of the following diseases?



Yes / No
Yes / No
Yes / No
Yes / No
Yes / No

5. Are there any other significant illnesses in your past? Yes | No




6. Do you have a Family history of any of the diseases listed below?



Condition YES OR NO Which family member?
Asthma Yes | No
Diabetes Yes | No
Heart Disease Yes | No
High Cholesterol Yes | No
High Blood Pressure Yes | No
Other: Yes | No
Yes / No