New Patient Registration

Personal details

Title (Dr, Ms, Miss, Mr, Mrs)>

First name

Middle name

Last name

Preferred name

Date of birth

Occupation

Email(Required)

Residential Address

Street Address(Required)

Suburb

Postcode

Country

Work Phone

Mobile Phone *(Required)

Home Phone

Emergency Contact Details

First name

Last name

Phone

Relationship

Medical & Health Information

Optometrist Name

Optometrist Address

GP Name(Required)

GP Address

Clinic Name

Are there any other doctors involved in your care? E.g. Cardiac specialist(Required)

Yes

Specialist Name

Specialist Address

Please list any forms of medication you take, amount and frequency of dosage. (If you have a summary of your medical history & medications, you may bring a copy to your appointment or attach in the “Attachment” box at the end of the form)

Do you have any allergies?(Required)

Yes

Do you have any current medications?(Required)

Yes

Please list any allergies or sensitivities(Required)

Current Medication

Please list any previous surgical procedures and year of surgery

Medicare & Private Health Insurance Information

Medicare Card - Do you have a Medicare card?

Yes

Medicare number

Position on card

Medicare Expiry

Is the patient under 18 years old?

Yes

Name of parent/guardian

Ralationship of parent/guardian

DOB of parent/guardian

Medicare Number of parent/guardian

Reference no

Expiry

DVA Card – do you have a DVA card?

Yes

DVA Card Number

DVA Card – Expiry date

DVA Card Type

Pension – Do you have a Pension Card?

Yes

Pension Number

Pension Expiry date

Do you have private health insurance?

Yes

Private Health Insurance Fund

Membership Number

Third Party Claims

File

You can upload a copy of your referral letter, medical history or any relevant information below:

Max. file size: 5 MB.

I understand that this Practice handles personal information in accordance with the National Privacy Principles enshrined in the Commonwealth Privacy Act 2012. I may gain access to my medical information, or provide permission for others to do so, by contacting Cataract & Eye Surgery Centre with a written and signed request. I consent to the handling and sharing of my information by this Practice for the purpose of my health care, research and for any associated administrative and billing purposes.I agree that photos/images may be obtained for my treatment, and for my Medicare or health fund requirements. I hereby agree to pay all associated fees relating to my consultation/s, tests and/or surgery or other expenses incurred in my treatment. I acknowledge that if an account is overdue, the Practice reserves the right to refer the account to a Collection Agency. I agree to meet all costs and commissions incurred in employing the said Agency to collect the overdue account. I am aware that in order for me to claim a Medicare rebate, I will need to provide a valid referral to my doctor on the day of consultation.

Untitled

I have read, understood and agree to the above

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CONSULTING DOCTORS

CATARACT

GLAUCOMA

REFRACTIVE & CORNEA

RETINA

OCULOPLASTICS

Personal details

Emergency Contact Details

Medical & Health Information

Medicare & Private Health Insurance Information