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Title

DR MISS MR MRS MS

First Name

Last Name

Middle Initial

Preferred Name

How do you identify yourself Aboriginal Torres Strait Islander Aboriginal & Torres Ethnicity A Australian

Ethnicity B - Please specify

Date of Birth

Home Address

City

State

Zipcode/Postcode

Country

-- Select Country -- AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA CÔTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JERSEY JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT BARTHÉLEMY SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT MARTIN SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SERBIA AND MONTENEGRO SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA VIETNAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE

Cell Phone Number

Work Phone Number

Home Phone Number

Would you like to have appointment reminders sent via SMS? Yes No

Email Address

Occupation

Medicare Number

Medicare Ref No.

Medicare Expiry Date

Local Pension/HCC Number

Local Pension/HCC Number Expiry

DVA Gold/White No.

DVA Gold/White Expiry

Next of Kin Name

Next of Kin Address

Next of Kin City

Next of Kin Postcode

Next of Kin Phone

Emergency Contact Name (if different to next of kin)

Emergency Contact Phone

Allergies Yes No Asthma Yes No Diabetes Yes No Hypertension Yes No Chronic illness Yes No Other Yes No

Other - Please specify

Current medications (including over the counter medications, vitamins and minerals)

Do you smoke? Yes No

How many cigarettes per day?

How many cigarettes per week?

Ex smoker? Yes No

Ceased Smoking

Do you drink alcohol? Yes No

How many drinks per day?

How many drinks per week?

Please list any vaccinations that you have had – ie. Tetanus/Flu/Hepatitis

Females: When did you last have a Pap Smear? Date Not sure Never

Females: When did you last have a Pap Smear Date

Females: When did you last have a Breast Check? Date Not sure Never

Females: When did you last have a Breast Check Date

Females: When did you last have a Mammogram? Date Not sure Never

Females: When did you last have a Mammogram Date

Females: When did you last have a Skin Check? Date Not sure Never

Females: When did you last have a Skin Check Date

Males: When did you last have an Overall Checkup? Date Not sure Never

Males: When did you last have an Overall Checkup Date

Males: When did you last have a Skin Check? Date Not sure Never

Males: When did you last have Skin Check Date

Prove you're not a robot

We will ask you to sign this form when you attend you appointment

*A fee of $88 will apply for appointments not attended or cancelled with less than 3 hours prior notice*

Opening Hours

 

Monday

8:00am - 6:00pm  

Tuesday

8:00am - 6:00pm  

Wednesday 

8:00am - 6:00pm  

Thursday

8:00am - 5:00pm  

Friday

8:00am - 5:00pm  

Saturday

8:30am - 11:30am

Sundays & Public Holidays

CLOSED     

Contact Details

Broome Medical Clinic

Phone: 08 9192 2022

Call now

Results Hotline : 08 9192 6690

Available daily: 12:30pm - 1:30pm

LIFE THREATENING EMERGENCIES: 000

After Hours Broome Hospital: 08 9194 2222