Online Patient Registration Form

If you are completing online registration, please email a copy of your doctors referral to email: office@malvernhillconsulting.com.au

Please fill out the following form to register as a patient at Malvern Hill Consulting once you have scheduled an appointment

Please note our online registration form is to be completed once your appointment has been booked at Malvern Hill Consulting. If you do not have an appointment please call 03 9188 3690 to arrange an appointment before registering online.

 
Mr Ms Mrs Miss Master Dr
M F Prefer not to disclose
Yes No
Yes No

Account Holder if patient is under 18 years of age:

Consent:

Fee Policy: 
All consultation fees are to be paid on the day of consultation. Malvern Hill Consulting does not bulk bill consultations. 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.

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.

 

You will receive a confirmation email once the registration form has been successfully uploaded.

Please email doctors referral to: office@malvernhillconsulting.com.au

Our services:
Our Specialists
Gallery
Australian Association of Otoloryngology Head & Neck SurgeryFellow of the Royal Australasian College of SurgeonsRoyal Australasian college of physiciansRoyal Australasian College of SurgeonsAustralian Medical Association