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)*
Medicare Expiry Date*
Usual GP Name*
Usual GP Location*
Patient is under 16?*
- 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*
Are there any current Family Court or other Court orders concerning the welfare safety or parenting arrangements of your child/children ?*
- Yes
- No
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

Do you hold a Pension Card?
- Yes
- No
Pension Card Details
Pension Card Category
Pension Card Number*
Card Expiry Date*
Are you a member of the Department of Veterans Affairs (DVA)?*
- Yes
- No
DVA Membership
DVA Card Level*
DVA Member Number*
Do you have private health insurance?*
- Yes
- No
Health Fund Details
Health Fund Coverage*
- Extras Cover Only
- Hospital Cover Only
- Hospital and Extras
Health Fund Name*
Membership Number*
Have you had Hospital Cover longer than 12 months?*
Date Joined*

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: $225.00 (medicare rebate $72.75)
Initial Pensioner Consultation: $180.00 (medicare rebate $72.75)
Follow up Consultation: $115.00 (medicare rebate $32.55)
Follow up Pensioner Consultation: $92.00 (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 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
Featured Patient*
Would you be interested in being an ENT Newcastle "Featured Patient"? Featured Patients agree to us sharing their photo and ENT story with others through our social media channels.
- Yes
- No

Patient Details