Patient Registration • Ear Nose Throat Newcastle

1 Patient Details

2 Account Information

3 Medical Information

4 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
Phone 1*
Phone 2
Email
Patient Medicare Number*
Patient Medicare IRN (1 digit next to patient's name)*
Patient Medicare Expiry Date*
Please put the day of expiry as the last day of the month
Usual GP Name*
Usual GP Location
Is the patient under 16 years of age?*
- Yes
- No
Guardian Details
Guardian Title*
Guardian Date of Birth*
Guardian Name*
Given Names Surname
Relationship to Child*
Guardian Phone Number*
Account Holder Medicare Number*
Account Holder Medicare IRN*
(1 digit next to cardholder's name)
Account Holder Medicare Expiry Date*
Please put the day of expiry as the last day of the month
Are there any current Family Court or other Court orders concerning the welfare, safety or parenting arrangements of your child/children that Dr Jefferson should be made aware of?*
- Yes
- No
Please explain any court orders that Dr Jefferson should be aware of
Emergency Contact
Emergency Contact Name*
Given Names Surname
Relationship to Emergency Contact
Emergency Contact Phone Number*
Have any of your family members attended our practice?*
- Yes
- No
Family Members
Family Member Name
Given Names Surname

What is the main reason for your referral to Ear Nose Throat Newcastle
- Tonsillitis
- Hoarse Voice
- Sinusitis
- Ear Infection
- Snoring
Further Information
Is there anything else you would like us to know?

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: $230.00 (medicare rebate $72.75)
Initial Pensioner Consultation: $185.00 (medicare rebate $72.75)
Follow up Consultation: $120.00 (medicare rebate $32.55)
Follow up Pensioner Consultation: $95.00 (medicare rebate $36.55)

Any procedure performed during the consultation will incur extra fees.
The fees charged for any procedures will be fully rebated through Medicare.
I agree to pay any and all fees associated with my consultation
- I Agree
Medical Record Photograph
We are committed to the highest level of security for our patients. At your first visit to our practice a photo will be taken of you. This photo will be stored securely with your medical record and will not be shared outside of your medical record.
- Opt in
- Opt out
Medical Photography*
Dr Jefferson 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. Dr Jefferson 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

Patient Details

Guardian Details

Emergency Contact

Family Members

Pension Card Details

Health Care Card Details

DVA Membership

Health Fund Details

Further Information