Patient Information Form

For your convenience, you can complete your Patient Registration Form online below.

The information submitted via this form is sent over a secure https SSL connection.

Patient Registration

Patient Details

Title

First Name

Surname

Address

Suburb

State

Postcode

Mobile Phone

Home Phone

Email

Date Of Birth

Emergency Contact

Emergency Contact Name

Emergency Contact Number (Mobile)

Medicare and Health Fund Details

Medicare No.

Reference Number

The number directly in front of your name. Eg 1

Expiry Date

Do you have Private Health Insurance?

Yes

No

Name of Health Fund

Membership Number

Ref (if applicable)

Do you have a Pension Card?

Yes

No

Pension Card Number

Expiry Date

Do you have a DVA card?

Yes

No

DVA Number (if applicable)

DVA Card Colour

Referrer Details

Name of Referring Doctor

Type

Usual Doctor/GP (if different to above)

Usual Doctor/GP Phone

Are you currently under the care of other medical practitioners you would like correspondence to be sent to i.e. Cardiologist, Vascular surgeon?

Yes

No

Please provide a Name, Address and Phone so we can send those details.

Workcover/Third Party/Public liability (if applicable)

Is this related to Workcover/Third Party/Public liability

Workcover

Third Party

Public liability

Insurance Company

Claim Number

Date of Injury

Case Manager

Phone Number

Email

Final Step

Please upload any relevant files (GP Referral, blood test results, urine test results, imaging report etc.)

Maximum file size: 10MB

Max. file size is 10mb. (Following files only. jpg, jpeg, png , gf, xls, doc, docm, docx, pages, pdf)

CONSENT TO COLLECT PATIENT

This medical practice collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs. We will 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 Commission requirements.
Disclosure to others involved in your health care, including treating doctors and specialists outside this medical practice as advised by you.

I 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 the health care and treatment given to me.
I am aware of my right to access the information collected about me, except in some circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.
I understand that if my information is to be used for any purpose other than the above, my consent will be sought.
I consent to the handling of my information by this practice for the purposes set out above, subject to any limitations on access or disclosure of which I may notify this practice.
I give consent to be part of the practice SMS appointment reminders.

Consent

I also give my permission to use Medicare Online Claiming and/or electronic account transmission on my behalf when required, and I assign my right to Medicare benefits to the Practitioner who rendered the service/s.

Full Name

Date

Signature

Clear

If you are human, leave this field blank.

Get In Touch

If you have a question or wish to make a booking, please contact us to find a convenient time and date. A GP referral is required.

Dr Prakash Damodaran

Neurosurgeon and Spine Surgeon