BP - New Patient Registration

First time with us?

Complete this form below to register before your appointment!

THINGS TO KNOW...

Completing this form is NOT the same as registering for online booking...BUT - you'll only need to complete both forms ONCE!

After your first visit, you'll be able to order prescriptions and updated referrals (conditions apply) this website!

How your information is used:

This form is used exclusively by CSMP to register you to visit your chosen GP.

Your GP only participates in de-identified research to better assess health trends and patient outcomes.

They also participate in a Quality Improvement programme that sends de-identified patient data to the Central and Eastern Sydney Public Health Network (CESPHN) to better look at the improve the delivery of patient care and health outcomes.

Surname:

First Name (as appears on Medicare Card):

Preferred Name:

Date of Birth

Sex (as recorded with Medicare):

Gender Identity:

Pronouns:

Ethnicity?

If you answered 'OTHER' above, please specify?:

Address:

Suburb:

Mobile Number:

Email Address:

Medicare Card Number

Position on Card:

Occupation:

Concession/Pension Card Number:

Next of Kin/Emergency Contact:

Next of Kin/Emergency Contact NUMBER:

Relationship to NOK/Emergency Contact?

Is your NOK/Emergency Contact a PATIENT at this practice?

Do you consent to receiving SMS reminders for your appointments and follow-ups?

Do you consent to receiving SMS messages for RESULTS follow-up?

If you have a My Health Record (MHR), do you consent to your GP accessing this to ensure continuity of your care?

Marital Status

ALLERGIES: Do you (or the person for whom you are completing this form) have any known allergies (i.e. nuts, pollen, etc.)?

MEDICATIONS: Are you currently taking any regular medications?

When is your appointment?

At what time?

Which doctor will you be seeing?

By completing this form, I declare that the information I have supplied is (to the best of my knowledge) complete and correct.

Opt-In

By checking this box, I confirm that I have read and understood the billing and fee structure of the GPs working at CSMP.

CONTACT

Phone: (02) 9516 2944

Healthlink EDI: churstmp

ADDRESS

280 Church St, Newtown 2042 NSW

HOURS

Mon - Fri: 8:00 am - 6:00 pm
Saturday: 8:00 am - 1:00 pm
Sunday: Closed