Patient Registration Form Registration Form Surname * Given Names * Date of Birth(YYYY-MM-DD if you are using IE) * Address Home phone Mobile Medicare No. Ref Expiry Veteran's Affairs No. Private Health Fund Membership No. Level of Cover Next of Kin Relationship Contact Nos. Privacy Statement: I agree to allow Elite Geriatric Care (EGC) Pty Ltd to pass on my personal details and medical information to other doctors, hospitals and medical services who will be involved in my medical management. In the event of surgery/emergency I allow EGC to contact my next of kin listed above to provide information regarding my condition. I agree and acknowledge that I am responsible for payment of medical accounts. Signed: (required) * Date * Patient Function Patient's Name Date of Birth Is the patient able to: 1. Get out of bed or chairs easily? Without helpWith a little helpWith a lot of helpCompletely unableNot known 2. Get dressed? Without helpWith some helpCompletely unableNot known 3. Eat their meals? Without helpWith some helpCompletely unableNot known 4. Go to the toilet? Without helpWith some helpCompletely unableNot known 5. Walk easily? Without helpWith some helpCompletely unableNot known 6. Shower or have a bath? Without helpWith some helpCompletely unableNot known 7. Manage their own medications? Without helpWith some helpCompletely unableNot known 8. Travel in the community? Without helpWith some helpCompletely unableNot known 9. Go shopping for groceries? Without helpWith some helpCompletely unableNot known 10. Prepare their own meals? Without helpWith some helpCompletely unableNot known 11. Do housework? Without helpWith some helpCompletely unableNot known 12. Manage their money? Without helpWith some helpCompletely unableNot known Anti-spam security text Please enter the text you see above * Required
