Patient Registration We request that all new patients complete the patient registration form before their first appointment. "*" indicates required fields Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Date of Birth* Mobile Phone* Email Address* Street Address Occupation Next of Kin (Family member or friend)Name Relationship to you Contact number Medicare & Health insuranceMedicare number* Ref number* Expiry* Private health insurance* Yes No Fund Name Fund Number Concession cardsAged or disability pension number Expiry date Dept veterans affairs card number Colour White Gold Expiry date Health care card number Expiry date Referrer detailsGP name* First Last Practice name* Practice Phone* Practice Address* Street Address Fee & Privacy PolicyFee Policy: All consultation fees are to be paid on the day of consultation. + $10 if not payable on the same day. 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 (Please call the rooms if you wish to further discuss the fees). 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 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.* Yes No I would LIKE TO OPT OUT OF INCLUDING HEALTH RECORDS FROM GASTROINTESTINAL SPECIALISTS INTO MY HEALTH RECORD* Yes No How did you hear about us? CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
