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Resources
GP and Other Clinicians Referral Form
New Patient Form
Contact
Register Online
Contact Us
Patient Registration Form
Your Details
Title*
Mr
Ms
Mrs
Miss
Gender
Male
Female
Country of Birth
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor-Leste)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Fiji
Finland
France
Gabon
The Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Macedonia
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
State*
New South Wales
Queensland, Northern Territory
Western Australia
South Australia
Victoria
Australian Capital Territory
Tasmania
Are you an Aboriginal and/or Torres Strait Islander?
Yes
No
Card Details
Medicare Card Number
Health Care Card
Pensioner Concession Card
DVA Card
Card Type
Gold
White
Relationship Status (Optional)
Relationship Status*
Single
Married
De Facto / Partner
Divorced
Widowed
Next of Kin (Optional)
Is this person also your Emergency Contact?
Yes
No
If NO, Emergency Contact details
Health History
Allergies
Severity
1
2
3
4
5
6
7
8
9
10
Smoking History
Never
Former Smoker
Current Smoker
Alcohol
Non-drinker
Rarely / Light
Moderate
Heavy
Do you engage in physical activities?
Yes
No
Do you use recreational drugs?
Yes
No
Medical/Surgical History
Please tick any relevant Medical/Surgical History
High Blood pressure
Heart Problems
Asthma/Lung Disease
Seizure/Epilepsy
Cancer (Type)
Kidney Disease
Kidney Disease
Stroke
Diabetes
Depression / Anxiety / Mental Illness
Blood clots
Pregnant
Do you have any other diseases or conditions that you are aware of?
Yes
No
Family History (Optional)
Please tick any relevant Medical/Surgical Family History
Diabetes
Heart Disease before the age of 60
Bowel cancer before the age of 55
Prostate cancer before the age of 60
Depression / Mental Illness / Anxiety
Breast cancer
Melanoma
Stroke
Ovarian cancer
Dementia or Alzheimer’s disease
COVID Diagnosis
Method
RAT
PCR
Symptoms (since having COVID)
Fatigue
Fatigue Severity
1
2
3
4
5
6
7
8
9
10
Breathlessness
Breathlessness Severity
1
2
3
4
5
6
7
8
9
10
Dizziness
Dizziness Severity
1
2
3
4
5
6
7
8
9
10
Cough
Cough Severity
1
2
3
4
5
6
7
8
9
10
Change in sense of smell or taste
Change in sense of smell or taste Severity
1
2
3
4
5
6
7
8
9
10
Mood problem
Mood problem Severity
1
2
3
4
5
6
7
8
9
10
Memory problem
Memory problem Severity
1
2
3
4
5
6
7
8
9
10
Chest pain
Chest pain Severity
1
2
3
4
5
6
7
8
9
10
Headache
Headache Severity
1
2
3
4
5
6
7
8
9
10
Insomnia
Insomnia Severity
1
2
3
4
5
6
7
8
9
10
Agreement
Our practice uses a reminder system to help maintain your health. The practice sends reminders by post, telephone or SMS for apt reminders.
I consent to being contacted with reminders to help maintain my health
Geelong Long Covid Clinic collects medical information for research and may consult with 3rd parties in the interest of your care using de identified data
I consent to my medical information being collected and used as required for my health.
Geelong long Covid clinic is a private clinic and full payment is required on the day they are provided. Any debt occurred in the recovering of the outstanding fees will be paid by the
I understand Geelong Long COVID clinic requires payment on the day of treatment, and I consent to do so.
Submit
