Patient Registration Form Patient DetailsName(Required) MissMrs.Ms.Mr.Mx.Dr.Prof. Prefix First Last Address(Required) Street Address Suburb Post code Date of Birth(Required)Gender(Required) Male Female Other Phone number(Required)Email(Required)Other detailsMedicare number(Required)Reference numberHealthfund Name:(Required)Policy Number:(Required)DVA Card(if applicable)Card colour:Number:Parent/Guardian/Account Holder DetailsIs the patient under 18 years old?(Required) Yes No Parent/Guardian/Account Holder Name(Required) First Last Parent/Guardian/Account Holder Address(Required) Street Address Suburb Post code Parent/Guardian/Account Holder Date of Birth(Required)Parent/Guardian/Account Holder Gender(Required) Male Female Other Parent/Guardian/Account Holder Medicare Number:(Required)Parent/Guardian/Account Holder Reference number:(Required)Referring DoctorReferring Dr Name(Required) DrDr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Clinic name(Required)Phone numberUsual GP Name (if different to above) DrDr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Usual GP Clinic Name (if different to above)How did you hear about us?Eg. GP/Specialist, google, word of mouth. ReferralUpload your referral and any relevant files: Drop files here or Select files Max. file size: 128 MB. Next of Kin Details – Other than Primary ContactName(Required) First Last Relationship to Patient(Required)Phone number(Required)Information ConsentWe require your consent to collect personal information about you. Please read this information carefully, and sign where indicated below. This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and a full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. This means we will use the information you provide in the following ways: Administrative purposes in running our medical practice. Billing purposes, including compliance with Medicare and Health Insurance Commission requirements. Disclosure to others involved in your health care, including treating Doctors and Specialists outside this medical practice. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following the referrals. Disclosure to other doctors in this practice, locums and registrars attached to the practice for the purpose of patient care and teaching. Please let us know if you do not want your records accessed for these purposes, and we will make a note in your record accordingly. Research, audit and other quality assurance activities to improve individual and community healthcare and practice management. I have read the information above and understand the reasons why my information must be collected. I am also aware that this practice has a privacy policy on handling patient information. This privacy policy can be found on our website or a hardcopy can be obtained upon request. I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the health care and treatment given to me. I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances. I understand that if my information is to be used for any other purpose other than set out above, my further consent will be obtained. I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I will notify this practice. I have the right to lodge a complaint about handling of my personal information if I am dissatisfied, which will be dealt with in accordance with the complaint handling procedure. If you (the patient) agree to the assignment of the Medicare benefit directly to the provider (bulk- bill), please tick and sign below*(Required) Yes, I agree to the assignment of the Medicare benefit directly to the provider.Consultation FeesConsultation Fees are payable in full on the day of consultation. Description Fee Rebate Out of pocket 104 – New Consultation $320.00 $88.40 $231.60 105 – Review Consultation $150.00 $44.45 $105.55 Some patients may require additional procedures during their consultation to assist with diagnosis or treatment. Examples include nasendoscopy (Item 41764), ear microinspection (Item 41647) and nasal cautery (Item 41677). These procedures incur an additional fee and attract a separate Medicare rebate. If performed, you will be asked to complete an Assignment of Benefit (AOB) form, authorising Medicare to pay the applicable rebate directly to the practice. Cancellation PolicyWe confirm patient appointments via SMS or Phone, it remains your responsibility to be aware of your scheduled appointment time. Please ensure that you respond to your appointment reminder, failure to do so will result in your appointment being automatically cancelled. 48hours notice is required for appointment cancellations, failure to do so will result in a $70.00 fee. Consent(Required) I agree to the cancellation policy.Patient Name:(Required) First Last Patient D.O.B(Required)Signature(Required)Date(Required) CAPTCHA
