New Patient Registration Form

To help streamline your visit and minimise paperwork on the day of your appointment, please complete this form online in advance.

Prefer to print? Download the blank form (PDF)

Personal Details

Title *

MrMrsMsDr

First Name *

Last Name *

Known As

Date of Birth *

Phone Number * (mobile or landline)

Email *

Street Address

Suburb *

State

Postcode

Emergency Contact Information

Full Name *

Phone Number *

Relationship to You *

Medicare, DVA & Concession

Medicare Card Number *

N/A

Individual Reference Number *

N/A

Medicare Expiry Date

DVA Card Number

DVA Card Expiry Date

DVA Card Colour

Centrelink Pension Card Number

Pension Card Expiry Date

Do you have private health insurance?

Medical History

Alcohol consumption

Do you smoke?

Do you have diabetes?

Do you have high blood pressure?

Do you have high cholesterol?

Family history of heart conditions?

Do you suffer from allergies?

Privacy Notice & Consent

Collection purpose: HeartWise Cardiology collects your personal and health information for the primary purpose of providing specialist cardiology care — including assessment, diagnosis, treatment planning, and follow-up.

Storage & security: Your information is stored securely in our clinical records system. Access is restricted to authorised staff and treating clinicians. Records are retained in accordance with Western Australian health records legislation.

Disclosure: Your information may be shared with healthcare professionals directly involved in your care (e.g. your referring GP, specialist consultants), Medicare/DVA for billing purposes, and, where required by law, regulatory or public health authorities. We do not sell or share your information for marketing purposes.

Sensitive health information: The health information you provide is sensitive personal information under the Privacy Act 1988 (Cth) and the Australian Privacy Principles (APPs). It will only be used or disclosed for the purposes described above or with your express consent.

⚠️ Urgent care limitation: This registration form is for non-urgent administrative purposes only. If you are experiencing a medical emergency, call 000 immediately or go to your nearest emergency department. Do not rely on this form for urgent or emergency care.

For full details, see our Privacy Policy. You have the right to access and correct information we hold about you — contact us at info@heartwisecardiology.com.au or (08) 6102 1655.

I have read and understood the above Privacy Notice. I consent to HeartWise Cardiology collecting, storing, and disclosing my health information as described above for the purpose of my cardiology care. *

Patient Signature *

Signature *

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By signing above, I confirm the information provided is accurate and I consent to its use for my healthcare.

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