Patient Registration Patient Registration Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix Surname Given name Preferred name Address Street Address Suburb Post code Phone - Home Phone - Mobile* Email* Occupation D.O.B Age Medicare number Reference number Expiry date Pension number Expiry date Veteran affairs no Private Health Fund Membership number Have you joined this fund /changed your policy within the last twelve months? Yes No Referring DoctorReferring Doctor details Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Clinic name Is your usual GP different to referring Doctor? Yes No Usual GP details Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Usual GP Clinic name Next of KinEmergency contact name First Last Phone - home Phone - mobile Relation to self Privacy Information and consentWe require your consent to collect personal information about you. Please read this information carefully, and sign where indicated below. Dr Sugandha Kumar's practice collects information from you for the purpose of providing quality health care. This means we will use the information you provide in the following ways: Administrative purposes in running the medical practice Billing purposes, including compliance with medicare Australia requirements Disclosure to others involved in your health care, including treating doctors and specialists outside the medical practice. This may occur through referral to other doctors, for medical tests and in the reports or results returned to us following the referrals. To contact you or your family for the purposes or recalls and reminders. Patient information shall not be released to a third party without the express consent of the patient I have read the information above and 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 health care and treatment given to me. I consent to the handling of my information of this practice and for the purposes set out above. Payment is required on the day of consultation. We accept credit cards, unfortunately not AMEX, EFTPOS and cash. Unfortunately we do not accept personal cheques. As a private specialist consulting service, this practice DOES NOT bulk bill. Name First Last SignatureDate
