Patient
Registration Form

Australian Pension Card

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DVA Gold Card

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Private Health Fund

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Emergency Contact Person

I understand that payment is required on the day of consultation. I understand the consultation fee is $690 (Medicare rebate of $240.75 applies). Testing if required will attract additional fees which will range from $705 to $960.

I understand that any follow-up tests and consultations will involve additional fees.

The fees have been explained to my satisfaction and a written quotation is available upon request.

If you have any questions or concerns regarding fees, please notify the reception staff immediately

As a patient of our medical practice we require you to provide us with your personal details and a full medical history, so that we may properly assess, diagnose, treat and be proactive in your healthcare needs. We aim to protect the privacy and secure storage of your health information. We require your consent to collect personal information about you and to use the information you provide in the following ways:

Administrative purposes in running our medical practice.
Billing purposes, including compliance with Medicare and Health Insurance requirements.
Disclosure to others involved in your healthcare including treating doctors and specialists outside this medical practice. This may occur through referrals to other doctors, or for medical tests and in the reports or results returned to us following referrals.
Disclosure to other doctors in the practice, locums etc. attached to the practice for the purpose patient care.
To comply with any legislative or regulatory requirements e.g. notifiable diseases.
For letters which may be sent to you regarding your health management and care.

Please read this consent form carefully, and sign where indicated below.

I have read the information above and understand the reasons why my information must be collected.

I consent to my mobile phone number being used to contact me for appointments and reminders.

Email usage is not routine and we will seek your consent in each event.

Enquiries and appointments

GP Event Request Rorm

Please select which events you would like to participate in, and we will get in touch with more information.

First Name

Last Name

Clinic Name

Address

Phone

Mobile Phone

Please select event of interest

On-site 'meet & greet' lunch Attend our next GP educational night/dinner Educational evening at your practice Visit our new facilities

Would you like to connect with us in another way?

Event suggestion

Coronary Artery Calcium (CAC) Scan Referral

Patient enquiry form

Resource request form

Please select which events you would like to participate in, and we will get in touch with more information.

First Name

Last Name

Clinic Name

Address

Phone

Mobile Phone

Please select resources of interest

Our latest newsletters Referral pad drop-off Mini Fact Sheet for GPs (Heart Attack Prevention)

Would you like to request other resources?

Reseource suggestion

Patient Registration Form

Enquiries and appointments

GP Event Request Rorm

Coronary Artery Calcium (CAC) Scan Referral﻿

Patient enquiry form

Resource request form

Patient
Registration Form

Coronary Artery Calcium (CAC) Scan Referral