Complete your patient registration

Prior to your appointment, please complete the patient registration below and return it to our office with your referral letter. This will allow more time with your doctor. On the day of your appointment, please bring your referral letter and Medicare card. Confidentiality is maintained at all times.

You can also email or fax the printable version of the Patient Registration Form to our office. See form for email and fax details.

Patient Registration Form

Child details

Name

Name of the child

First Name

Last Name

Date of birth

The child's date of birth

Family details

Address

Home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent 1 name

if the surname is different the child's, please specify.

First Name

Last Name

Parent 1 mobile

Parent 1 work number

Parent 2 name

First Name

Last Name

Parent 2 mobile

Parent 2 work number

Referral

The referring doctors details

Referring Doctor

Referring Doctor's name.

First Name

Last Name

Address

Address of the Referring doctor

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Referring doctor's phone & fax

Date referred

Provider number

Local Doctor

Name of your local doctor, if different to the referring doctor.

First Name

Last Name

Local Doctor's address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Local Doctor's phone & fax

Medical information

Medicare number

Medicare reference (number)

The number next to your name on the Medicare card.

Medicare expiry

Pension number

Pension type

Pension expiry

Private health provider

Name of your health fund.

Membership number

Your private health memebership number

Drug Allergies

Please list all your child's allergies.MR

Medical record number (MRN)

(if applicable)

Medicare rebate

You can claim Medicare rebate from our office. This means that you pay your account in full at the time of your consultation and our reception staff transmits the claim directly to Medicare. The rebate is paid to you by Medicare by either EFT or cheque. If you would like to receive an EFT payment, please provide the details below. I agree to use Telehealth where appropriate and assign the appropriate Medicare Benefits to the doctor or claim the benefit after payment to the doctor. Please cross out: YES/ NO

Parent's name

First Name

Last Name

Date of birth

DOB of the parent

Medicare reference number

The number next to your name on the Medicare card

Your Email:

“Please bring your referral letter and Medicare card on the day of your appointment.”

Registration form

Complete your patient registration