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)*
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 OR over 16 but on parent's Medicare Card?*
- Yes
- No
Account Holder Details
Please fill out account holder details below for Medicare claiming purposes
Parent/guardian title*
Parent/Guardian Date of Birth*
Parent/Guardian Name*
Given Names Surname
Parent/Guardian Medicare Number*
Parent/Guardian Medicare IRN*
(1 digit next to cardholder's name)
Parent/Guardian Medicare Expiry Date*
Please put the day of expiry as the last day of the month
Emergency Contact
Must be different from the details entered above
Title*
Name*
Phone*
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
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: $230.00 (medicare rebate $73.85)
Initial Pensioner Consultation: $185.00 (medicare rebate $73.85)
Follow up Consultation: $120.00 (medicare rebate $37.15)
Follow up Pensioner Consultation: $95.00 (medicare rebate $37.15)

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
Procedures*
I agree to be bulk billed for any procedures performed by Dr Niall Jefferson in his private rooms, with a valid Medicare card and referral
- I agree
Medical Record Photograph
We are committed to the highest level of security for our patients. 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*
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

Account Holder Details

Emergency Contact

Emergency Contact

Family Members

Pension Card Details

Health Care Card Details

DVA Membership

Health Fund Details