Client Questionnaire

    Title:MrMrsMsMissOther
    First Name:
    Last Name:
    Preferred Name:
    Date of Birth:
    Gender: FMOther
    Home Address:
    Suburb:
    Postcode:
    Email:
    Phone Number:
    Mobile preferred as we send appointment reminders via SMS.
    Medicare No:
    Ref. No:
    Exp:

    It is important that we have some information about your cultural background in order to provide appropriate care.

    What is your ethnicity?
     (Prefer not to disclose)
    Do you identify as Aboriginal and/or Torres Strait Islander? NoYes - AboriginalYes - Torres Strait IslanderYes - Aboriginal & Torres Strait Islander

    Emergency Contact: In the event of an emergency, please provide details of whom we should contact.

    Name:
    Phone:
    Relationship:

    Next of Kin: If different from above.

    Name:
    Phone:
    Relationship:

    Do any of your family members currently attend Turn the Corner Medical Clinic?

    Communication from Turn the Corner

    • We operate a recall system for matters of clinical significance. We send appointment reminders and secure links to certain test results via SMS if we have your mobile phone number on file.
    • We participate in a personalised reminder program for preventive health issues such as skin checks and annual health assessments. We also produce an e-newsletter every month or so with Clinic information and relevant general health information to our clients.

    If you do NOT wish to receive reminders and emails I do NOT wish to receive reminders and emails please tick this box.

    Under 16s only – Parent / Guardian details

    First Name:
    Last Name:
    Date of Birth:
    Medicare No:
    Ref. No:
    Exp:

    Finally – your agreement

    “I have read and agree to the Clinic’s Terms and Privacy policy, and agree to pay the fees associated with the services I receive or ask to receive from Turn the Corner Medical Clinic”.