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Patient Registration Form

Prefix

Surname

First name

Preferred name

Birthday

Day

Month

Year

Occupation

Address - Street number and name

Suburb

Post code

Mobile phone

Home phone

Referring Doctor

Clinic

Is your referring Doctor the same as your GP?

Yes

Medicare Number

Ref Number

Expiry

Pension/Health Care Card?

Yes

Private Health Insurance?

Yes

Veterans Affairs Card?

Yes

Emergency Contacts

Next of Kin

Relationship

Contact Number

Is your Emergency Contact the same as your Next of Kin?

Yes

This information is required for the primary purpose of providing quality health care. We need you to provide us with your personal details and full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. 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 HIC 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 referral.

I have read the information above and understand the reasons why information must be collected. I understand that I am not obliged to provide any information, but that my failure to do say may compromise the quality of the health care given to me. I am aware of my right to access the information collected about me, except in some circumstances where access may 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 than set out above, subject to any limitations on access or disclosure that I notify this practice of, I consent to the retrieval of medical information, including reports and results from medical tests from others involved in my health care, including treating doctors, specialists, hospitals and health care professionals.

I have been provided with information regarding Dr Amanuel Tesfai's fees and understand that I am responsible for payment of these fees on the date of service, and that fees are subject to change. I understand that if it has been more than 15-months from my last consultation an initial consultation fee will apply

Although it is not necessary to have a current referral to see the doctor, I understand that to obtain a Medicare rebate it is my responsibility to ensure I maintain a current referral for each appointment. I understand that a referral from a GP lasts 12-months and from a specialist lasts 3-months.

Signature

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