Patient Registration

Doctor You Have Appointment With

Title

First Name

Last Name

Date of Birth

Gender

Sex at Birth

Street

Suburb

Postcode

State or Territory

Primary Contact Number

Home or Work Number (Optional)

Occupation (Optional)

Medical Conditions, Current Medications and Allergies

Medicare & Health Cover Details

Medicare Number (if Available)

Medicare Reference

Pension Number (Optional)

War Veterans Number (Optional)

Private Health Fund (if Applicable)

Private Health Fund Membership Number

Do You Have Hospital Cover?

Have You Had Hospital Cover for More Than 12 Months?

Work Cover or TAC Claim Number (If Applicable)

Employers Address (for work cover claim)

Account Holder/Parent Details (if Patient Is Under 18 Years of Age)

Account Holder/Parent Details
(if Patient Is Under 18yrs)

Name

Relationship

Date of Birth

Medicare Number

Medicare Reference

Emergency Contact

Next of Kin Name

Relation to Patient

Next of Kin Contact Number

GP Details

Clinic Name

Usual Practitioner (Optional)

Consent

Fee Policy

All consultation fees are to be paid on the day of consultation.

Malvern Hill Consulting is not a bulk billing practice, however, in the event a service is bulk billed, I agree to the assignment of the Medicare benefit directly to the health professional. I understand that I will have to pay the fee in full if I do not consent.

A valid DVA, TAC or other form of approved Work Cover is accepted. The costs for any surgical out of pocket expenses will be discussed with reception following your consultation. Failure to attend a booked appointment, without prior notification, will incur a cancellation fee.

Privacy

We require you to provide us with your personal details and medical history so that we may properly diagnose, treat and be proactive in managing your health care needs. This practice handles personal information in accordance with the Victorian Health Records Act and the Commonwealth Privacy Act.

I consent to the handling of my information by this practice for the purpose of providing quality health care, associated administrative and billing purposes. I give permission for medical information to be obtained from any other source in order to help with my treatment and to be disclosed to others involved in my health care, including treating doctors and specialists outside this medical practice as advised by you.

I understand that despite all appropriate precautions being taken, protection of my personal information cannot be guaranteed.

By submitting this form I agree that I have read the above fee policy and privacy statement, and consent to the taking and use of my medical records as described, and I agree to pay the costs of consultations and any surgical procedures performed.

Fee Policy

All consultation fees are to be paid on the day of consultation.

Privacy

I understand that despite all appropriate precautions being taken, protection of my personal information cannot be guaranteed.