Patient Registration "*" indicates required fields Name* Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Address* Street Address Suburb Postcode Telephone (Home) Telephone (Work) Telephone (Mobile)* Email* Date of birth: Occupation: Local Doctor (GP): Medicare number: Expiry date: Patient Reference: Aged Pension / Health Care Card No: Expiry Date: Veteran’s Affairs File No: Type: Gold card White card Next of Kin Name: First Last Next of Kin Phone: Do you have Private Health insurance? Yes No Insurer: Membership No: MEDICAL HISTORYDo you suffer from: Diabetes: Yes No Heart Disease: Yes No High Blood Pressure: Yes No Asthma/Bronchitis: Yes No Have you had any major illnesses or operations?Do you take blood thinning tablets (ie: Warfarin, Aspirin, Plavix)Do you take any medications?Are you allergic to anything? Do you have a family history of breast or ovarian cancer? Have you been through menopause? Yes No If yes- do you or did you use HRT? Yes No How long for? PRIVACY POLICYThis practice is committed to ensuring high level privacy for all personal health information including photographic records collected, used and disclosed in the course of effective patient care. During this process, both collection and sharing of health information with other medical and allied health professionals may be necessary. This may include for patients with breast cancer diagnosis, entry of de-identified data into the Breast Quality Audit (BreastSurgANZ) and case discussion at Multi-Disciplinary Team meetings at the Alfred Hospital, Monash Health, The Epworth and Peninsula Private Hospital. I consent that photographs be taken of me if required. I understand that these photographs form an essential part my medical record, as well as my preoperative and postoperative assessment. I understand and consent to my photographs being used for medical research, teaching or patient education purposes. I understand that I will not be identified by name in any such use of these photographs nor will my identity be recognisable. This medical practice collects information for the primary purpose of providing quality health care. This information is used to provide medical care and for administrative purposes, billing and compliance with Medicare requirements. Information may be sent to other Practitioners involved in your care and we may request your relevant past medical history. We will always endeavour to maintain your confidentiality. Any medical data used in research, quality assurance or for educational purposes will not be identified. Should my health information be required for purposes other than those listed above I understand that my further consent will be required. A copy of the 29 Specialist Centre’s privacy policy is available on request. FEES FOR THIS PRACTICEI understand that I am being seen as a private patient and understand that fees/charges will apply. There will be a gap between the Medicare Rebate and the amount charged which must be met by the patient. There will also be an extra charge if a procedure is performed on the day which also must be met by the patient. The AMA recognises that Medicare benefits are fixed by the federal government and that benefit levels have not kept pace with inflation, the costs of running a practice and medical indemnity, thereby widening the gap between reasonable fees and Medicare benefits. The fees charged by this practice are considered as being fair, reasonable and appropriate for the services provided. I further understand that this practice does not BULK BILL. I acknowledge that if my account is overdue my Practitioner, at her discretion, reserves the right to refer the account to a third party. I agree to meet all reasonable costs incurred by my Practitioner in employing the said third party to recover overdue monies.PATIENT DECLARATIONSignature*Date* DD slash MM slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
