North Melbourne ENT

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Patient Registration

Services
Our Doctors
Info Sheets
Contact
Request an Appointment
Patient Registration

Patient Registration Form

Williamstown

- Step 1 of 7

Patient Details

Title

Mr
Mrs
Ms
Miss
Master
Dr
Other

Name *

First

Last

Preferred Name

Date of Birth *//

Age

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Home Phone

Work Phone

Mobile Phone *

Email *

Occupation

Medicare Number *

Reference Number (position on card) *

Expiry

Emergency Contact Details

If patient is under 18 years, please include date of birth and Medicare number of account holder for billing purposes.

Name *

First

Last

Relationship *

Phone *

Date of Birth

Medicare Number

Reference Number

Expiry

Billing Address For Medicare Rebate

Address Line 1

City

State / Province / Region

Postal Code

Country

DVA

Does this attendance relate to Veteran's Affairs?

Yes
No

Card Number *

Type *

Gold
White

Private Health Insurance (Hospital Cover)

Do you have private health insurance (hospital cover)? *

Yes
No

Private Health Fund (Hospital Cover) *

Member Number *

WorkCover / TAC Claims

Is this appointment related to a WorkCover or TAC claim? *

Yes
No

Claim Number *

Regular GP Details

Name *

First

Last

Clinic *

Information for Consultation

Main Reason For Visit Today *

Medication

Please list current medications and dosages (including over the counter pain medication and vitamins): *

Allergies

Do I Suffer From Allergies? *

Yes
No

Please specify *

Medical History

Are you pregnant? *

Yes
No

Do you have a history of any of the following illnesses / conditions?

Bleeding problems
High blood pressure
HIV / AIDS
Heart problems
Rheumatic fever
Asthma
Hepatitis
Diabetes

Please list previous surgeries and when they occurred as well as any medical problems and when they started, including dates

Family history of cancers / serious medical problems

Anaesthetic

Have you or your family members ever had any problems after an anaesthetic? *

Yes
No

Please specify

Fee Policy

This is a private billing practice and therefore full payment of fees are required on the day of your consultation(s). If surgery is required, a written Informed Financial Consent will be provided to you prior to your procedure which will outline your surgeon’s fees. These fees are required to be paid at least one week prior to your procedure. In the event that your overdue account is referred to a collection agency and/or law firm, you will be liable for all costs which would be incurred as if the debt is collected in full, including legal demand costs. By signing this form you are agreeing to the above fee policy. Please speak to the receptionist prior to your appointment should you not be in agreement. I have read and understand the above statement.

Signature *

Date *//

Privacy Policy

This practice collects your information in order to identify your medical record and provide an accurate, quality health service. I consent to the collection of my personal information for the purposes of administration, billing and disclosure to others involved in my medical care outside of this practice, for the purpose of ongoing health care.

Signature *

Date *//

Need help filling out this form?
If you need assistance with completing your patient registration form, please phone our Williamstown office on 03 9397 5507 between 9am and 5pm, Monday to Friday.

North Melbourne ENT

We are ear, nose and throat surgeons based in North Melbourne and Williamstown.

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North Melbourne
Address: 100/30 Wreckyn St, North Melbourne VIC 3051
Phone: (03) 9078 8074
Fax: (03) 9078 8105

Williamstown
Address: 54 Electra Street, Williamstown VIC 3016
Phone: (03) 9397 5507
Fax: (03) 9397 6914

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