New patient form

Healthengine Limited (ACN 138 767 021) has been engaged by your health practice / health practitioner to assist with booking of appointments and provision of health-related services. The use of Healthengine's new patient form service is optional.

If you wish to proceed, please complete all fields and submit this form before your appointment. This form will be provided to the practice that you have booked an appointment with. Your personal information will be kept private and secure.

If the appointment was booked by you on behalf of someone else, please fill in the form with the details of the patient attending the appointment. To complete the form you will need the following:

• Medicare card
• Veteran affairs, pension or any other health care card
• Private health insurance details
• Contact details of next of kin and emergency contact
• Details of any current medication

Please note that for security reasons any information entered into this form will be wiped after 3 minutes of inactivity. If this happens, the form will need to be filled in from the beginning. We therefore recommend having all information ready before starting the form.