Consumer Registration Form

Please fill out all mandatory fields marked with an asterisk *

PERSONAL DETAILS

Title

First Names*

Surname*

Preferred Name

DOB*

Day

Month

Year

Gender*

What pronoun do you use?

For example: she/her, he/his, they/them
Learn more about pronouns : QHRC : Why pronouns matter.

COMMUNICATIONS

Preferred method of contact?*

Can we email?

Yes No

Home Phone

Please include area code without spaces (e.g. 0299998888).

Can we leave a message for you?

Yes No

Work Phone

If not a mobile, please include area code without spaces (e.g. 0299998888).

Can we leave a message for you?

Yes No

Mobile

Please enter 10 digital number without spaces (e.g. 0499888888).

Can we SMS you?

Yes No

Can we leave voicemail?

Yes No

ADDRESS

Do you have a fixed home address?*

Yes No

Street Address

Address*

Suburb*

State*

Postcode*

Postal Address

Use street address?

Yes No

Address

Suburb

State

Postcode

MEDICARE

Do you have a Medicare Card?

Yes No

Medicare Card No (10 digit card number e.g. 1234567890)

Reference No (the number next to your name)

Expiry Date (e.g. 01/2099)

HEALTH CARE CARD

Do you have a Health Care Card?

Yes No

HCC Number

HCC Expiry Date (e.g. 01/2099)

EMERGENCY CONTACT / NEXT OF KIN

Next of Kin

Do you have a Next of Kin Contact?*

Yes No

Name*

Relationship*

Phone*

If not a mobile, please include area code without spaces (e.g. 0299998888).

Address

Can we tell them about your appointment?*

Yes No

Emergency Contact

Do you have an Emergency Contact that is different?*

Yes No

Name*

Relationship*

Phone*

If not a mobile, please include area code without spaces (e.g. 0299998888).

Address

Can we tell them about your appointment?*

Yes No

CULTURAL BACKGROUND AND ADDITIONAL NEEDS

Are you of Aboriginal or Torres Strait Islander origin?*

Country of Birth*

What cultural or ethnic group do you identify with?*

Ethnicity 1
Ethnicity 2
Ethnicity 3
Ethnicity 4
Ethnicity 5
Ethnicity 6

Do you need an interpreter? If yes, which language?*

Yes No

Language*

HEALTH

Do you have any disabilities and/or additional needs?*

Yes No

If yes, how can we make you comfortable?*

Do you have any allergies?*

Yes No

Allergy	Reaction