Patient Registration • Ear Nose Throat Newcastle

1 Patient Details

2 Account Information

3 Privacy, Billing and Consent

Appointment Date*

Do not complete this form unless you have a confirmed appointment at Ear Nose Throat Newcastle.
Patient Details
Title
Name*
Given Names Surname
Gender*
Date of Birth*
Address*
Street Address Suburb State Postcode Country
Contact number*
Do you consent to receiving appointment reminders and recalls via text message?*
- Yes
- No
Email
Patient Medicare Number*
Patient Medicare IRN (1 digit next to patient's name)*
Usual GP Name*
Usual GP Location
Are there any current court orders concerning the patient's welfare that our doctors and nurses should be made aware of?*
- Yes
- No
Please explain any court orders that your ENT should be aware of
Have any of your family members attended our practice?*
- Yes
- No
Family Members
List Family Members and their relationship to you.
Please list one family member per line

Privacy*
I understand that the practice keeps my information safe and secure in accordance with the national guidelines. To read our privacy policy click here. I understand that my information may be disclosed to other individuals involved in my health care outside of this practice
- I Understand
Fees*
I understand that payment is required on the day of service via cash, EFTPOS or cheque, and that failing to attend will incur a fee.

* Initial Consultation: $310.00 (medicare rebate $95.10)
* Follow up Consultation: $190.00 (medicare rebate $47.80)
I agree to pay any and all fees associated with my consultation
- I Agree
Procedures*
I agree to be bulk billed for any small procedures performed by the Doctor in his private rooms, with a valid Medicare card and referral
- I agree
Medical Record Photograph
This photo will be stored securely and will not be shared outside of your medical record. Upload a photograph now for your medical file.
Medical Photography*
Your ENT may take photos inside of your ears, nose or throat. These photos are stored securely within your medical record. These photos do not contain any identifying features. Your ENT may use these images for teaching purposes without your name attached.
- Opt in
- Opt out
Social Media*
Ear Nose Throat Newcastle love ensuring that our social media and website are kept up-to-date. If our staff see a photo opportunity whilst you are in the practice, would you be happy for your photo to be used on our social media pages and website?
- Yes
- No
Debt Collection*
All accounts will be sent to debt collection if they remain unpaid after 14 days. I understand that a debt collection fee will be added to my invoice if this occurs.
- I understand
Signature*
By signing below you agree that all of the information entered above is correct

Patient Details

Family Members

Account Holder Details

Emergency Contact

Health Fund Details

Pension Card Details

Health Care Card Details

DVA Membership