Patient Registration Form

    CONFIDENTIAL INFORMATION

    Personal Information
















    YesNo

    If you have selected yes to having private health insurance, please fill out the following details. Otherwise if you have selected no, please move onto the Next of Kin / Emergency Contact section.






    Next of Kin / Emergency Contact




    GP details if different from referring doctor




    Paediatric/Special Needs Patients

    (only complete this section if the patient is aged less than 18 or unable to legally give consent, otherwise move onto next section)




    YesNo


    Pre-existing Medical Conditions




    YesNo


    Advance Care Directive Plan


    Privacy & Financial Consent

    (a copy of our privacy policy is available on request)


    • where required by law

    • when requested by another medical practitioner/hospital including emergency medical care

    I understand that I will incur out-of-pocket expenses and that fees are due and payable on the day of consultation. A 20% surcharge + GST may apply to accounts not paid on the day of consultation.



    Yes