Client Questionnaire

Title:MrMrsMsMissOther
First Name:
Last Name:
Preferred Name:
Middle Initial:
Gender: FMOther
Date of Birth:
Home Address:
Suburb:
Postcode:
Email:
Phone Number:
Mobile preferred as we send appointment reminders via SMS.
Medicare No:
Ref. No:
Exp:
DVA Gold/White:
Exp:
Pension/HCC:
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 you have any allergies or sensitivities?

YesNo
If so, what happens?

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

Some optional questions

Occupation:
Hours per week:
Sexuality: HeterosexualHomosexualBisexualPrefer not to disclose

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”.