New Patient Form

Welcome to the rooms of Dr. Khoury.
Please complete our new patient form below, prior to your upcoming Initial Consultation.

Prefix

Name

First Name

Last Name

Date of Birth

Phone Number

Address

Please enter your address

Emergency Contact + Phone Number

Your GP Clinic

Recent XRAY/ Images

In the last 3 months have you had any scans / xrays or MRI? If so, please list the imaging centre below

Medicare No.

Your medicare number / ref / expiry

Are you a smoker

Are you a Diabetic?

Do you have any medical history we should be aware of?

Example: cardiac disease, or family history of cardiac

Are you Privately Insured ?

Are you a DVA Cardholder?

If your care is part of a Workcover/ TAC claim?

If so, please enter the Claim Number below. Please note that all initial claim consultations are required to paid on the day and you will need to seek reimbursement from your provider.

Your Private Health Fund & Membership No.

Have you had Private Health for longer than 12 months?

Do you have any pre-existing conditions that we should know?

Your Health Providers

Please list any other Health Providers you would like any communications to forwarded to.

Private Hospital Preference

Privacy Statement

PRIVACY STATEMENT: In accordance with the Privacy Legislation effective from 21 December 2001, it is a requirement to obtain your consent to collect, use and disclose personal information regarding your treatment and continuing health care. We ask you to provide us with your personal details and medical history for the primary purpose of providing quality healthcare. Relevant information necessary to assist your treatment and continuing health care may be passed onto the following * Other medical practitioners / specialists *Pathology / Radiology *Medicare / Health Funds *Hospitals *Physiotherapists *Other health care professionals

Medical Record Keeping

By submitting this form, you consent to the use of iScribe AI medical scribing for the purpose of efficient record keeping. This transcription data is retained on their server for a maximum of 60days.

New Patient Form

Our team are available Monday to Thursday 9am – 4pm with our additional private after-hours service.