• Opening Hours

    Monday-Friday:8am-6pm
    Public Holidays: Closed

    CBD Location

    Level 1, 70 Pitt Street
    Sydney, NSW 2000
  • Registration Form- PRINT AND BRING WITH YOU

    the doctors at 70 Pitt St
    PATIENT HISTORY FORM
    Print, complete and bring
    PERSONAL DETAILS (please note that ID may be required to confirm these details)
    Surname: Given Name: Title:
    Date of Birth: Address:
    Home Phone: Mobile: E-mail:
    Occupation: Work Phone:
    Medicare No: Reference No: Expiry:            /
    Are you of Aboriginal or Torres Strait Islander Descent? (Please Circle) YES NO
    Emergency Contact / Next of Kin Name: Relationship:
    Emergency Contact / Next of Kin Phone Number:
    MEDICAL HISTORY
    Height: Weight:
    Medical History – Including Current Do you have any allergies or adverse drug reactions?
    Year Condition/Operation Substance Reaction
    Immunisations Current Medications
    Date Type Type Dose Frequency
    Smoker YES / NO qty p/d Alcohol Consumption YES / NO qty p/w
    WHEN WAS YOUR LAST:
    Type Date Result
    BLOOD TEST
    BREAST SCREEN
    MAMMOGRAM
    PAP SMEAR
    PROSTATE CHECK
    FAMILY HISTORY
    HIGH BLOOD PRESSURE YES / NO ALLERGIES YES / NO
    HIGH CHOLESTEROL YES / NO HEART ATTACK YES / NO
    DIABETES YES / NO STROKE YES / NO
    CANCER YES / NO OTHER YES / NO
    DISCLAIMER:
    It is important to complete this form correctly to the best of your knowledge, to enable us to provide treatment safely and with
    minimal risk to your wellbeing. Our practice respects your privacy and any information given in this form or in person will remain
    strictly confidential. I hereby accept responsibility for payment of any fees in full on the day of treatment.
    I understand I will be charged a broken appointment fee of $50 if I fail to provide 24h notice of cancellation for all future appointments.
    Signature:* Date:
    *(signature of parent/guardian if patient is under 16 years of age)