Patient Registration Form Patient registration form "*" indicates required fields Select your appointment locationSelect Location* Chatswood: Chatswood Retina Bondi: Eastern Suburbs Eye Specialists Concord: Concord Eye Specialists Penrith: Nepean Ophthalmic Surgeons Liverpool: South West Retina Campbelltown: Macarthur Eye Specialists Narellan: Macarthur Eye Specialists You are completing the patient registration for . If you have selected the wrong location by mistake, please reload the page to start again.Patient DetailsPatient name* MrMrsMsMissMasterDrProfOther Title Surname Given Name Preferred NameDate of birth* DD slash MM slash YYYY Patient email address* A copy of this form will be sent to this addressMain phone number*Main number, enter mobile or landlineAlternate phone number #1Alternate phone number #2Gender Male Female Other OccupationHome address* Street Address Suburb State Post code Postal Address diff to home address my postal address is different to my home address Postal address (if different to Home address) Street Address Suburb State Post code Emergency Contact DetailsEmergency contact name* MrMrsMsMissMasterDrProfOther Title Surname Given Name Main phone number*Enter mobile or landline numberAlternate phone number #1Alternate phone number #2Relationship to patientCard DetailsDo you have a medicare card? Yes No (eg. overseas visitor) Medicare number (10 digits)Reference (number next to patient name)Expiry date (MM/YYYY)Do you have a pension card? Yes No Government pension type Aged Disability Customer reference number (CRN)Expiry date (DD/MM/YYYY)Do you have a Department of Veteran's Affairs (DVA) card? Yes No Card type Gold White Orange File numberExpiry date (DD/MM/YYYY)Is this visit related to Worker's Compensation/Third Party? Yes No Worker's compensation numberCase manager nameCase manager contact numberCase manager emailDo you have private health insurance for hospital? Yes No Private health fund nameMembership numberReference number (No. next to your name on card)Level of cover Gold Silver Bronze Basic Other Medical Professional DetailsGP/Family DoctorNamePractice Name and AddressPhone Add RemoveOptometristNamePractice Name and AddressPhone Add RemoveOther specialistsNamePractice Name and AddressPhone Add RemoveConsent to the collection of personal information*Collection of Personal Information, Privacy Act 1988 (Cth) and Health Records and Information Privacy (HRIP) Act 2002 (NSW). We ask you to provide us with your personal details and medical history so that we may optimally diagnose and treat illnesses and be proactive in your healthcare. Clinical imaging in the form of scans, photography and video recording may also be considered to be information that is collected from you. We may use the collected information in the following ways: Administrative and billing purposes – i.e. in the running of our medical practice. Adherence to Medicare and Health Insurance Commission compliance requirements. Disclosure to others involved in your healthcare, including treating doctors outside this medical practice. Disclosure to other doctors, registrars or students, for the purpose of teaching Disclosure for research and quality assurance activities to improve individual and community healthcare and practice management. We may have to share your personal information with third parties who work with our practice for business purposes, such as accreditation agencies or information technology providers. Our practice has a privacy policy which contains information about accessing and seeking collection of personal information, and has a privacy complaints handling process. I have read the information above and understand the reasons why my information must be collected. I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of my healthcare. I consentPayment of fees*Please note that private health insurance in Australia does not cover consultations, tests or treatments performed by specialists outside of a hospital. A Medicare rebate will however cover a part of the fees within a medical practice if you have a valid referral and Medicare card. Fees are payable on the day of consultation. These fees include: The consultation fee, and Any additional tests or treatments, the costs of which will be discussed with you beforehand. While a Medicare rebate applies to most items, please note that Optical Coherence Tomography (OCT) scans are usually not covered by Medicare. I agree to pay on the day for all services received. I understand that the practice does not issue accounts. I have read and understand the information above.Submit your informationAll information entered in this form is sent securely. Please review your responses before submitting. Your personal information is not stored on this website.
