New Patients

We invite you to fill out the patient registration form below online in advance to make your appointment experience even smoother. We require all patients to register prior to seeing a specialist.

    PATIENT REGISTRATION FORM

    TITLE:

    MRMRSMSMISSMASTER

    SURNAME

    GIVEN NAMES

    DATE OF BIRTH

    TELEPHONE (HOME)

    MOBILE

    WORK

    EMAIL ADDRESS

    ADDRESS

    POST CODE

    MEDICARE

    MEDICARE CARD EXPIRY

    REF#

    DO YOU HAVE PRIVATE HEALTH INSURANCE

    NoYes

    NAME OF FUND

    MEMBERSHIP NO.

    NEXT OF KIN

    TELEPHONE

    PARENT/GUARDIAN DETAILS (If under 18)

    NAME

    ADDRESS

    POST CODE

    TELEPHONE

    DATE OF BIRTH

    MEDICARE

    REF#

    Do you suffer any drug allergy?

    NoYes

    Please specify:

    Had a COVID swab in the last 14 days?

    NoYes

    Southeast ENT Clinicians use Al transcription software to accurately record a transcript of your consultation enabling them to produce more accurate notes for the patient, carers and referring Doctors. No recordings are kept, and all transcripts/letters are generated in accordance with Southeast ENT’s privacy policy. If you have any queries or concerns please bring it to the attention of the administration staff. For more information of Al Transcription software, please visit: https://www.i-scribe.com.au

    Please tick the relevant box below and sign to indicate your consent for Al note and letter writing.:

    NAME

    SIGNATURE

    Sign with your cursor in the box below

    DATE

    By ticking this box you acknowledge our Consulting fees and agree with our Privacy Policy. Should you have any enquiry please contact the front desk staff before signing this document.