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Registration Form

Registration Form

    Hidden fields

    Personal / Contact details:

    Medicare / Health Care Card / Pension card:

    Emergency Contact:

    Please provide details below:

    Privacy policy

    Poets Corner Medical Centre is committed to maintaining the confidentiality of your personal health information. It ls policy of this Practice to maintain the security of personal health information at all times and to ensure that this Information Is only available to authorised Practitioners.

    Patient’s Details

    Alcohol Assessment

    If You Answered Never, No Need To Answer The Following Questions

    Smoking Assessment

    Family History Screening Questionnaire:

    This risk assessment focuses on your close relatives, including parents, children, brothers, and sisters who are either living or dead. If answered yes to any question, please state who. *(Only first and second-degree relatives need to be considered in this screening questionnaire).