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

REF#

VETERAN’S AFFAIRS (IF APPLICABLE)

DO YOU HAVE PRIVATE HEALTH INSURANCE NoYes

NAME OF FUND

MEMBERSHIP No.

NEXT OF KIN

TELEPHONE

PARENT/GUARDIAN DETAILS (If patient is under 18 years old)

NAME

ADDRESS

POST CODE

TELEPHONE

DATE OF BIRTH

MEDICARE

REF#

Do you suffer any drug allergy? NoYes

Please specify:

COVID-19 Screening
Please answer all of the following questions:

Have you, or anyone in your household, had a COVID swab in the last 14 days? NoYes

Do you, or anyone in your household, work in place affected by a recent COVID outbreak? NoYes

Have you, or anyone in your household, travelled overseas in the last 14 days? NoYes

Have you, or anyone in your household, being in contact with a confirmed case of COVID-19? NoYes

Do you have a cough? NoYes

Do you have a sore throat? NoYes

Do you have a runny nose? NoYes

Do you have unexplained shortness of breath? NoYes

Do you have a recent loss of your sense of smell and/or taste? NoYes

Please contact our staff if you have answered "YES" to any of these questions prior to your appointment at Southeast ENT.

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.